Abstract
BackgroundSignificant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis. Symptoms related to significant PVL may be difficult to differentiate from those related to other causes of heart failure. Cardiovascular magnetic resonance (CMR) directly quantifies valvular regurgitation, but has not been extensively studied in symptomatic post-TAVR patients.MethodsCMR was compared to qualitative (QE) and semi-quantitative echocardiography (SQE) for classifying PVL and prognostic value at one year post-imaging in 23 symptomatic post-TAVR patients. The primary outcome was a composite of all-cause death, heart failure hospitalization, and intractable symptoms necessitating repeat invasive therapy; the secondary outcome was a composite of all-cause death and heart failure hospitalization. The difference in event-free survival according to greater than mild PVL versus mild or less PVL by QE, SQE, and CMR were evaluated by Kaplan-Meier survival analysis.ResultsCompared to QE, CMR reclassified PVL severity in 48% of patients, with most patients (31%) reclassified to at least one grade higher. Compared to SQE, CMR reclassified PVL severity in 57% of patients, all being reclassified to at least one grade lower; SQE overestimated PVL severity (mean grade 2.5 versus 1.7, p = 0.001). The primary and secondary outcomes occurred in 48% and 35% of patients, respectively. Greater than mild PVL by CMR was associated with reduced event-free survival for the primary outcome (p < 0.0001), however greater than mild PVL by QE and SQE were not (p = 0.83 and p = 0.068). Greater than mild PVL by CMR was associated with reduced event-free survival for the secondary outcome, as well (p = 0.012).ConclusionIn symptomatic post-TAVR patients, CMR commonly reclassifies PVL grade compared with QE and SQE. CMR provides superior prognostic value compared to QE and SQE, as patients with greater than mild PVL by CMR (RF > 20%) had a higher incidence of adverse events.
Highlights
Significant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis
Patients Cardiovascular magnetic resonance (CMR) was performed in 23 post-TAVR patients with New York Heart Association (NYHA) class III-IV symptoms
Aortic regurgitation quantification is more reproducible by CMR compared to echocardiography for native valve disease [13,14], it is noteworthy that quantitative regurgitant fraction (RF) values of aortic regurgitation severity obtained by phase-contrast magnetic resonance (PCMR) are systematically lower than those obtained by echocardiography [15,16]
Summary
Significant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis. Symptoms related to significant PVL may be difficult to differentiate from those related to other causes of heart failure. Cardiovascular magnetic resonance (CMR) directly quantifies valvular regurgitation, but has not been extensively studied in symptomatic post-TAVR patients. Despite extensive pre-procedure evaluation, greater than mild paravalvular leak (PVL) occurs in over 10% of patients undergoing TAVR and is associated with worse short and long term outcomes [3,4]. Accurate identification of post-TAVR PVL by cardiac imaging is essential, as symptoms from PVL may be difficult to clinically differentiate from symptoms related to other common causes of heart failure, such as systolic and diastolic dysfunction. The purpose of our study was to evaluate CMR in post-TAVR patients in whom there was concern for clinically significant PVL. In addition to PVL classification, we assessed the ability of CMR findings to predict outcomes at one year post-imaging
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