How TAVR valve implant depth impacts clinical outcomes
When cardiologists perform transcatheter aortic valve replacement (TAVR) with a self-expanding valve, securing a higher implant depth is associated with improved clinical outcomes. That was the primary takeaway from a new one-year analysis published in JACC: Cardiovascular Interventions.[1]
“TAVR has become an established therapy across the full surgical risk spectrum, with ongoing efforts focused on procedural refinement and long-term durability,” wrote first author Danny Dvir, MD, director of interventional cardiology at the Shaare Zedek Medical Center, and colleagues. “Among technical factors, implantation depth has emerged as a potentially modifiable determinant of clinical outcomes.”
Dvir et al. explored data from Optimize PRO, a Medtronic-funded study of more than 600 patients who underwent transfemoral TAVR at one of 50 facilities around the world from 2019 to 2023. All patients received an Evolut Pro or Evolut Pro+ TAVR valve from Medtronic. The mean age was 79.1 years old, and 47% of patients were women.
Researchers used aortography to determine the core laboratory-adjudicated noncoronary cusp implant depth for each patient. Patients were categorized based on that final implant depth.
- Group 1: <1 mm
- Group 2: 1 to ≤3 mm
- Group 3: >3 to ≤5mm
- Group 4: >5mm
Immediate outcomes
Higher implant depths were linked to a reduced risk of resheathing and recapture. The overall rate of resheathing and recapture was 41.3%. For the individual patient groups, however, the rates were 27.3% for Group 1, 33.7% for Group 2, 48.8% for Group 3 and 77% for Group 4. Also, the median length of stay was one day for patients with a higher implant depth and two days for patients with a lower implant depth.
Pre-implant balloon valvuloplasty, post-implant dilatation, valve migration and valve embolization, on the other hand, occurred at comparable rates for all groups.
One-year outcomes
After one year, the combined endpoint of all-cause mortality and stroke occurred in 9.7% of TAVR patients. This included an all-cause mortality rate of 4.6%, a stroke rate of 6% and a disabling stroke rate of 2.7%. The permanent pacemaker implantation (PPI) rate for the entire cohort was 12.8%, and the left bundle branch block (LBBB) rate for the entire cohort was 27.8%.
Most of these patient outcomes were comparable for all patient groups after one year. On a similar note, the rates of myocardial infarction, clinical valve thrombosis and valve endocarditis were low for all patient groups.
One key difference, however, was the fact that higher rates of PPI and LBBB were seen in patients with lower/deeper implant depths.
Mean gradients and effective orifice area were comparable for all implant depths, the authors added.
“The main finding of the comprehensive evaluation of this large observational analysis about implantation depth and clinical outcomes after TAVR is that a higher implantation position was associated with favorable early clinical outcomes, without an increase in procedural safety events,” the authors wrote. “Higher positioning was also associated with fewer device repositioning maneuvers (resheath/recapture) and a shorter hospital stay, while rates of device malposition, embolization, coronary obstruction, and other major procedural complications remained similarly low across implantation depths.”
Dvir and colleagues also highlighted the difference between operator-assessed implant depth and core laboratory-assessed implant depth.
“On average, operators assessed device position as approximately ~2 mm higher than measured by the core laboratory, with a larger discrepancy in the left than in the non-cusp depth assessment,” the group wrote. “That significant difference underscores the importance of standardized imaging assessment and may have implications for procedural guidance and quality control.”
Looking ahead, the authors said future studies should examine the long-term impact of implant depth on “valve durability, coronary access and the feasibility of redo procedures.”
“A key unresolved question remains: at what point is high too high?” they asked. “As TAVR continues to expand into younger and lower-risk populations, optimizing implantation strategy will require balancing early clinical benefits with the potential complexity of future interventions.”
Click here for the full analysis in JACC: Cardiovascular Interventions, an American College of Cardiology journal.
Click here for a previous look at Optimize Pro.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.