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• W4211217978 abstract "Central MessageEx vivo studies must adequately approximate physiologic conditions and clinical criteria to reach useful conclusions.See Article page 28. Ex vivo studies must adequately approximate physiologic conditions and clinical criteria to reach useful conclusions. See Article page 28. In this issue of the Journal, Samaee and coauthors1Samaee M. Hatoum H. Biersmith M. Yeats B. Gooden S.C. Thourani V.H. et al.Gradient and pressure recovery of a self-expandable transcatheter aortic valve depends on ascending aorta size: In vitro study.J Thorac Cardiovasc Surg Open. 2022; 9: 28-38Scopus (3) Google Scholar present a study on the effect of ascending aortic (AA) size on the hemodynamics and pressure recovery (PR) in self-expanding transcatheter aortic valves (SEVs). They placed a 26-mm Evolut R valve in a heart simulator flow loop with 3 different aortic sizes, 23 mm, 28 mm, and 34 mm. The flow solution was at room temperature (25° C). They then measured center line pressures below the valve, at the valve level, and 5 mm downstream from the valve. This allowed them to measure the PR between the valve and the AA. The concluded that the 26-mm Evolut valve has greater peak and mean pressure gradients when deployed in small AA due to constraints from the AA. In the retrospective clinical part of the study, the authors demonstrate the phenomenon of PR, which has been well-established in patients with prosthetic valves and AA <30 mm and accounts for the discrepancy between the pressure gradients measured noninvasively by Doppler and those measured invasively by catheterization.2Bach D.S. Echo/Doppler evaluation of hemodynamics after aortic valve replacement: principles of interrogation and evaluation of high gradients.JACC Cardiovasc Imaging. 2010; 3: 296-304Crossref PubMed Scopus (61) Google Scholar It is therefore not surprising that the PG Doppler–PG cath was greater in patients with small AA, as this can be explained by the PR phenomenon rather than any valvular dysfunction. Clinically, however, the net pressure gradient calculated between the left ventricle and the AA is more relevant and takes into account the PR. The central message of the study that AA size is important in valve choice is true and is a part of procedural planning. Nonetheless, there are several issues to highlight with the study design. The SEV's nitinol frame is temperature-sensitive and designed to fully expand at body temperature (37° C). However, the study was conducted at a lower temperature of 25° C, which is not reflective of physiological conditions and will not allow for full valve expansion where not in contact with the model (valve cage section). In addition, given their design, flow loops do not take into account the tissue–device bidirectional interaction, which would ultimately influence valve hemodynamics. The SEV landmark clinical trials, based on core laboratory–read computed tomography angiography scans of the CTA, did not include patients with small AA dimensions measuring 23 mm or less. A 26-mm Evolut valve would be considered inappropriate for use and oversized in this scenario. This inappropriate use would account for the greater gradients and high pinwheeling index resulting from distal frame constraint. The conclusions drawn need to be taken in the context of nonphysiological testing conditions and AA sizes not included or studied in SEV clinical trials. Results from the CHOICE (Randomized Comparison of Transcatheter Heart Valves in High Risk Patients With Severe Aortic Stenosis: Medtronic CoreValve vs Edwards SAPIEN XT) randomized clinical trial demonstrate no significant difference in clinical outcomes between SEV and balloon-expandable valves but favored flow hemodynamics in SEV, similar to previously published studies.3Hahn R.T. Leipsic J. Douglas P.S. Jaber W.A. Weissman N.J. Pibarot P. et al.Comprehensive echocardiographic assessment of normal transcatheter valve function.JACC Cardiovasc Imaging. 2019; 12: 25-34Crossref PubMed Scopus (93) Google Scholar,4Abdel-Wahab M. Landt M. Neumann F.J. Massberg S. Frerker C. Kurz T. et al.5-year outcomes after TAVR with balloon-expandable versus self-expanding valves: results from the choice randomized clinical trial.JACC Cardiovasc Interv. 2020; 13: 1071-1082Crossref PubMed Scopus (66) Google Scholar In vivo evaluation of different transcatheter heart valve gradients in patients with small AA, such as the current SMART trial (Small Annuli Randomized to Evolut or SAPIEN Trial; NCT04722250), will shed light on the interaction between different transcatheter heart valves and AA under physiologic settings and better model reality. Gradient and pressure recovery of a self-expandable transcatheter aortic valve depends on ascending aorta size: In vitro studyJTCVS OpenVol. 9PreviewIn this study we aimed to understand the role of interaction of the Medtronic Evolut R transcatheter aortic valve with the ascending aorta (AA) by evaluating the performance of the valve and the pressure recovery in different AA diameters with the same aortic annulus size. Full-Text PDF Open Access" @default.
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• W4211217978 date "2022-03-01" @default.
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• W4211217978 title "Commentary: Does this model reality?" @default.
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• W4211217978 doi "https://doi.org/10.1016/j.xjon.2022.02.003" @default.
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