Zero-Contrast TAVR: Inching Toward Safer TAVR in Patients With Kidney Disease

Nicholas Kassis; Marwan Saad

doi:10.1016/j.jscai.2024.102251

August 14, 2024Journal of the Society for Cardiovascular Angiography & InterventionsOpen Access

Zero-Contrast TAVR: Inching Toward Safer TAVR in Patients With Kidney Disease

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Why the study?

Does a zero-contrast TAVR protocol utilizing preprocedural noncontrast CT for valve sizing achieve accurate sizing and safe clinical outcomes in patients with severe aortic stenosis and advanced chronic kidney disease?

Structured PICO

Does a zero-contrast TAVR protocol utilizing preprocedural noncontrast CT for valve sizing achieve accurate sizing and safe clinical outcomes in patients with severe aortic stenosis and advanced chronic kidney disease?

P

Population

Patients with severe tricuspid aortic stenosis and advanced chronic kidney disease not yet on renal replacement therapy undergoing balloon-expandable SAPIEN valve TAVR (training cohort n=100, validation cohort n=60, and clinical series n=35 at high risk of requiring hemodialysis; clinical series had mean age 79 ± 11 years, mean eGFR 21.5 ± 9.2 mL/min/1.73 m2, 31.2% with reduced left ventricular systolic function, 14.3% with concomitant cardiogenic shock, and 57.1% undergoing urgent/emergent TAVR).

I

Intervention

Zero-contrast TAVR with moderate sedation using a preprocedural noncontrast CT chest algorithm (incorporating sinotubular junction diameter, sinus of Valsalva diameter, and sex) for balloon-expandable SAPIEN valve sizing, intraprocedural pigtail catheter as a reference depth for valve deployment, and transthoracic echocardiography to evaluate postdeployment valve function.

O

Outcome

Correlation of the sizing algorithm with actual valve size, and procedural/clinical outcomes including technical procedural success and need for new post-TAVR hemodialysis.safety

Limitations

Conducted at a single high-volume center
Algorithm was designed only for balloon-expandable SAPIEN valves in a small cohort of patients with tricuspid AS, limiting generalizability to other valve platforms, bicuspid AS, or valve-in-valve TAVR
Proposed valve sizing algorithm had an average risk of 9.4% undersizing and 14.4% oversizing
Inability of noncontrast CTA to precisely evaluate the risk of coronary obstruction (such as coronary heights, valve-to-coronary distance, valve-to-STJ distance, and leaflet-STJ mismatch)

Implication

This editorial highlights a promising proof-of-concept algorithm using noncontrast chest CT for zero-contrast TAVR sizing in patients with advanced chronic kidney disease, though risks of valve oversizing and unmeasured coronary obstruction warrant caution and further multicenter evaluation.

Abstract

The expanding indications of transcatheter aortic valve replacement (TAVR) to treat aortic stenosis (AS) warrants continued improvement in patient safety and outcomes, particularly among those at disproportionally high risk. Patients with chronic kidney disease (CKD) are considered one such high-risk group that is well-represented among patients with severe AS. Although data have emerged demonstrating the reversibility to baseline CKD after TAVR,1 patients with impaired baseline renal function are at elevated risk of developing postoperative acute kidney injury, and the presence of both portend worse in-hospital,2 midterm,3 and long-term1 outcomes following TAVR.

Discussion

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Cite This Study

Kassis et al. (2024) studied this question.

synapsesocial.com/papers/6a725536e36a167817e3cc8b https://doi.org/10.1016/j.jscai.2024.102251

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Zero-Contrast TAVR: Inching Toward Safer TAVR in Patients With Kidney Disease

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Zero-Contrast TAVR: Inching Toward Safer TAVR in Patients With Kidney Disease

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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