Pushing the Margins with Symetis ACURATE: A Suitable Prosthesis for Low Coronaries and Valve-in-valve TAVI Procedures

Objectives: The self-expandable Symetis ACURATE valve (Boston Scientific, USA) has been used in our clinic since 05/2011 for the transapical (TA) and since 03/2015 for the transfemoral (TF) approach. Sparse information is available in unfavorable TAVI-cases, such as patients with low coronary distance to the annulus (≤8 mm) or Valve-in-Valve (VinV) procedures in degenerated bioprosthesis. Here we report about a single center experience of 242 Symetis Acurate TAVI procedures.

Methods: From 05/2011 until 09/2017, 242 Symetis ACURATE valves were implanted in 122 TA- and 120 TF cases. Mean age in TA was 80.8 ± 7.6 years and in TF 82.3 ± 5.6 years. Porcelain aorta occurred in 24 (19.7%) TA-cases and in one (0.8%) TF case.

Results: Conversion to surgical aortic valve replacement was necessary in one TF case with ventricular embolization (0.4%). Second instant valve-in-valve was needed in four shifted valves (1.7%); two in each approach. Permanent pacemaker rates were 12.8% in all, 18.0% in TA- and 7.5% in TF-groups. 30day mortality rates were 3.7% in all, 5.7% in TA- and 1.7% in TF-groups. Further parameters were summarized in [Table 1]. Coronary distance of ≤8 mm to the annulus occurred in 23 patients (9.5%) and was 7.0 ± 1.3 mm (range 3–8 mm); 17 patients (13.9%) were treated via TA- and 6 (5.0%) via TF-approach. In the TA-subgroup, one coronary occlusion occurred and was solved by instant percutaneous stent implantation. 30day mortality was 8.7% (2/23) resulting from the TA group. VinV was done in 9 cases (3.7%; TA, n = 8; TF, n = 1). One VinV patient with low coronary distance died on day 9 due to asystole.

Conclusion: In our opinion, the Symetis ACURATE - especially the TA valve - is suitable for TAVI-patients with delicate findings, such as low coronaries, degenerated bioprosthesis and porcelain aorta. The TF valve convinced with its short stay in hospital, and its low 30day mortality rate. In this cohort, embolization happened during the learning curve and could be managed quick and safely.

Table 1 Values are mean ± SD or N (%)

	Transapical (n = 122)	Transfemoral (n = 120)
Female	66 (54.1)	89 (74.2)
OP time (min)	121 ± 107	71 ± 54
Stay in hospital (d)	15.9 ± 8.7	11.5 ± 5.0
Contrast agent (ml)	142 ± 68	185 ± 62
Paravalvular leakage—none/trace	46 (37.7)	61 (50.8)
Mild	54 (44.3)	42 (35.0)
Mild/moderate	17 (13.9)	14 (11.7)
Moderate	5 (4.1)	2 (1.7)