Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02302-4
Transcatheter heart valve in challenging anatomy – comparison of balloon expanding Sapien 3 Ultra and self-expandable Acurate neo2 in patients with horizontal aorta
B. R. H. Wasif1, C. Eckel1, W.-K. Kim2, C. Grothusen1, V. Tiyerili1, D. Sötemann1, M. Renker2, G. Dohmen3, Y.-H. Choi4, E. I. Charitos4, C. W. Hamm5, A. Elsässer6, J. Blumenstein1, H. Möllmann1
1Klinik für Innere Medizin I, Kath. St. Paulus Gesellschaft, Dortmund; 2Abteilung für Kardiologie, Kerckhoff Klinik GmbH, Bad Nauheim; 3Klinik für Herz-, Thorax- und Gefäßchirurgie, Kath. St. Paulus Gesellschaft, Dortmund; 4Herzchirurgie, Kerckhoff Klinik GmbH, Bad Nauheim; 5Medizinische Klinik I - Kardiologie und Angiologie, Universitätsklinikum Gießen und Marburg GmbH, Gießen; 6Klinik für Kardiologie, Klinikum Oldenburg AöR, Oldenburg;

Background: Challenging anatomies and comorbidities have impact on success in transcatheter aortic valve implantation (TAVI). There is controversy in the literature regarding the topic of horizontal aorta (HA), particularly whether the extent of the aortic angle has an impact on procedural outcomes especially in different THV systems. Matched comparative outcome data of 3rd generation transcatheter heart valves (THVs) in dedicated anatomic situation of HA are scarce.

Methods: Data from 1582 patients with severe native aortic stenosis (AS) treated with the SAPIEN 3 Ultra(Ultra; n=526) or ACURATE neo2 (Neo2; n=1056) THVs from January 2017 to January 2023. After exclusion of patients with non-horizontal aorta (< 51.7°, n=881), the population was matched by 1-to-1 nearest-neighbor matching to identify one patient treated with Ultra (n=246) for one patient treated with Neo2 (n=246). Clinical and procedural outcome were evaluated according to VARC-3 recommendations. 

Results: Technical success (93.1% vs. 93.5%, p=1.000) and device success (80.5% vs. 89.4%, p=0.008) were high after 30 days with Ultra and Neo2, respectively. The rate of in-hospital complications was low and comparable between both groups, see Table 1. Neo2 reveals superior hemodynamic properties with lower rate of severe prosthesis patient mismatch (12.0% vs. 4.1%, p=0.003) and lower rate of elevated gradients (11.9% vs. 1.7%, p<0.001). Ultra shows lower rate of relevant paravalvular regurgitation (0.0% vs. 3.3%, p=0.007) with tendency towards more major cardiac structural complications (2.4% vs. 0.8%, p=0.285). There was no difference in rate of procedural bailout maneuvers (0.8% vs. 0.8%, p=1.000) and thirty-day all-cause mortality (1.3% vs. 2.6%, p=0.334). 

Conclusion: Transfemoral TAVI in patients with severe native aortic stenosis and horizontal aorta is feasible and safe using Sapien 3 Ultra and ACURATE Neo2 prosthesis. No relevant procedural aspects such as embolization or the need for bailout maneuvers between prostheses were observed. The development of prostheses as well as the increasing experience of interventionalists seems to outweigh the initial difficulties of the TAVI procedure in patients with horizontal aorta.
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