Severe Paravalvular Aortic Regurgitation Research Articles

Ultra-low radiation dose and contrast volume CT protocol and TAVI-CT score for TAVI planning and outcome.

To investigate the feasibility of an ultra-low radiation dose and contrast volume protocol using third-generation dual-source (DS) CT for transcatheter aortic valve implantation (TAVI) planning with coronary artery disease (CAD) assessment, coronary artery calcium score (CACS) and aortic valve calcium score (AVCS) quantification and to evaluate their relationship with TAVI outcome. In this retrospective study were selected 203 patients (131 males, 79.4 ± 5.4 years) underwent to TAVI and at 30- and 90-day follow-up. All patients had performed a third-generation 2 × 192-slices DSCT. The CT protocol included a non-contrast and a contrast high-pitch aortic acquisition for TAVI planning and CAD assessment. Semi-qualitative and quantitative image analysis were performed; the performance in CAD assessment was compared with ICA; the relationship between AVCS and CACS and paravalvular aortic regurgitation (PAR) and major cardiovascular events (MACEs) were evaluated. Mean radiation dose were calculated. Non-parametric tests were used. Semi-qualitative image analysis was good. Contrast enhancement >500 Hounsfield unit (HU) and contrast-to-noise ratio <20 were obtained in all segments. The diagnostic accuracy in CAD was 89.0%. AVCS was significantly higher in patients with 30-day severe PAR. AVCS and CACS were higher in patients with 90-day MACE complications, respectively, 1904.5 ± 621.3 HU (p < 0.0001) and 769.2 ± 365.5 HU (p < 0.0230). Mean radiation dose was 2.8 ± 0.3 mSv. A TAVI planning ultra-low radiation dose and contrast volume protocol using third-generation DSCT provides highly diagnostic images with CAD assessment, AVCS and CACS quantification and these latter were related with TAVI outcomes. The proposed protocol using third-generation 2 × 192-slices DSCT allows with an ultra-low radiation dose and contrast volume the TAVI planning and the coronary artery assessment.

Haemodynamic performance and clinical outcomes of transcatheter aortic valve replacement with the self-expanding ACURATE neo2.

Transcatheter aortic valve replacement (TAVR) with the ACURATE neo device has been associated with a non-negligible incidence of paravalvular aortic regurgitation (AR). The new-generation ACURATE neo2 has been designed to mitigate this limitation. The aim of the study was to compare TAVR with the ACURATE neo and neo2 devices. The NEOPRO and NEOPRO-2 registries retrospectively included patients undergoing transfemoral TAVR with self-expanding valves at 24 and 20 centres, respectively. Patients receiving the ACURATE neo and neo2 devices (from January 2012 to December 2021) were included in this study. Predischarge and 30-day VARC-3 defined outcomes were evaluated. The primary endpoint was predischarge moderate or severe paravalvular AR. Subgroup analyses per degree of aortic valve calcification were performed. A total of 2,026 patients (neo: 1,263, neo2: 763) were included. Predischarge moderate or severe paravalvular AR was less frequent for the neo2 group (2% vs 5%; p<0.001), resulting in higher VARC-3 intended valve performance (96% vs 90%; p<0.001). Furthermore, more patients receiving the neo2 had none/trace paravalvular AR (59% vs 38%; p<0.001). The reduction in paravalvular AR with neo2 was mainly observed with heavy aortic valve calcification. New pacemaker implantation and VARC-3 technical and device success rates were similar between the 2 groups; there were more frequent vascular and bleeding complications for the neo device. Similar 1-year survival was detected after TAVR (neo2: 90% vs neo: 87%; p=0.14). TAVR with the ACURATE neo2 device was associated with a lower prevalence of moderate or severe paravalvular AR and more patients with none/trace paravalvular AR. This difference was particularly evident with heavy aortic valve calcification.

Left ventricular outflow tract pseudoaneurysms and severe paravalvular aortic regurgitation treated by percutaneous approach in a Marfan syndrome patient

A 66-year-old male with a history of Marfan syndrome and resolved infective endocarditis was found to have shortness of breath after a previous aortic valve replacement in 2010. Several severe paravalvular leaks were seen on imaging, and left ventricular outflow tract pseudoaneurysms were identified as the cause of his symptoms which warranted treatment. Due to this patient’s risk of surgical intervention, a retrograde transaortic approach was used.

Paravalvular Aortic Regurgitation Severity Assessed by Quantitative Aortography: ACURATE neo2 versus ACURATE neo Transcatheter Aortic Valve Implantation.

The new-generation ACURATE neo2 system was commercially released in September 2020. In this study, we sought to compare the aortic regurgitation (AR) severity of the ACURATE neo2 versus the ACURATE neo transcatheter heart valve, using quantitative videodensitometric angiography (qAR). This is a retrospective, Corelab analysis of final post-transcatheter aortic valve implantation (TAVI) aortograms of patients treated with the ACURATE neo2 and ACURATE neo systems. The ACURATE neo2 cohort comprised consecutive patients treated between September 2020 and January 2021 at two centers. The ACURATE neo cohort included consecutive patients treated before September 2020. Our primary objective was to compare AR severity on qAR following TAVI with ACURATE neo2 and ACURATE neo. Out of 401 aortograms, 228 (56.9%) were analyzable, with 120 in the ACURATE neo2 cohort, and 108 in the ACURATE neo cohort. The mean AR fraction was 4.4 ± 4.8% in the neo2 cohort, and 9.9 ± 8.2% in the neo cohort (p < 0.001). Furthermore, moderate or severe AR (qAR > 17%) was detected in 2 aortograms (1.7%) in the neo2 cohort and 15 aortograms (13.9%) in the neo cohort (p < 0.001). Quantitative aortography shows a lower rate of moderate or severe paravalvular AR in what is the first European experience of the new-generation, self-expanding ACURATE neo2 when compared to the first-generation ACURATE neo. Moreover, aortographic data need to be correlated and compared to Core Laboratory-adjudicated 30-day echocardiographic data.

P1811 Prognostic impact of different subtypes of severe aortic stenosis undergoing transcatheter aortic valve implantation

Abstract Background Outcomes for different subtypes of aortic stenosis defined by transvalvular flow and gradient after transcatheter aortic valve implantation (TAVI) are still subjects of debate. Purpose The aim of the study was to evaluate the prognostic impact of the initial transvalvular flow rate and aortic mean gradient on survival and to assess the changes of left ventricular function after TAVI. Patients and Methods From 2008. to 2017.06.30. TAVI was performed in 300 cases in our Institute (127 men, 173 women, mean age 80,0 ± 5,8 years) with severe (aortic valve area &amp;lt;1,0 cm²) symptomatic aortic stenosis (AS) and contraindication or high risk for surgery. Median time for follow-up was 28 (0-115) months, Echocardiography was performed before and 12 months after TAVI. Patients were divided into four groups according to flow (F) , aortic mean gradient (Gr) and ejection fraction (EF): HG Gr ≥ 40 mmHg (n = 237) LF-LG : F ≤ 35 ml/m2, Gr &amp;lt; 40 mmHg and EF &amp;lt; 50% (n = 41) PLF-LG: F ≤ 35 ml/m2, Gr &amp;lt; 40 mmHg and EF ≥50% (n = 9) NF-LG: F &amp;gt; 35 ml/m2 and Gr &amp;lt; 40 mmHg (n = 13) Our primary objective was the analysis of 30-day, 1-year and 3-year all-cause mortality of these groups, secondary goal was to observe the changes in EF after 12 months in the survivors. Results In the whole patient group 30-day all-cause mortality was 4,3%, 1-year 17,0% and 3-year 62,0%. The NFLG group had the most favourable outcomes (mortality: 30d 0, 1-year: 7,7%, 3-year: 46,2%). Mortality was low in the HG group in the 1st year (30-day: 3,8%, 1-y: 14,3%), but it increased to 62,8% at 3-year. Mortality rates were intermediate in the PLF-LG group (30-day 0, 1-year 22,2%, 3-year 55,6%) and were the highest in LF-LG (30-day 12,2%, p = 0,03 vs HG, 1-year 34,2% p = 0,005 vs. HG, 3-year 75,6%). Among clinical and echocardiographic variables only moderate or severe paravalvular aortic regurgitation (p = 0,03) and severe renal dysfunction (GFR &amp;lt;30 ml/min, p = 0,02) were independent predictors of all-cause 1-year mortality. In patients with severe (EF &amp;lt; 30%) , moderate (EF 30-40%) or mild ( EF 41-50%) systolic dysfunction the EF improved after TAVI (23,5 ± 3,5% vs. 30,3 ± 7,9% p &amp;lt; 0,001, 33,6 ±3,6% vs. 43,0 ± 10,5% p = 0,003, 45,5 ± 3,1% vs. 54,3 ± 8,7% p &amp;lt; 0,001) regardless of the initial flow and gradient subtype of AS. Conclusions Low flow-low gradient aortic stenosis is associated with worse short or long term prognosis after TAVI, therefore this subtype of AS needs detailed risk stratification before-, and careful management after TAVI. Improvement of initial left ventricular dysfuncion can be expected after TAVI.

Comparison of transcatheter aortic valve implantation with other approaches to treat aortic valve stenosis: a systematic review and meta-analysis

BackgroundTranscatheter aortic valve replacement (TAVI) is an alternative treatment for patients with symptomatic severe aortic stenosis ineligible for surgical aortic valve replacement (SAVR) or at increased perioperative risk. Due to continually emerging evidence, we performed a systematic review and meta-analysis comparing benefits and harms of TAVI, SAVR, medical therapy, and balloon aortic valvuloplasty.MethodsWe searched MEDLINE, Embase, and Cochrane CENTRAL from 2002 to June 6, 2017. We dually screened abstracts and full-text articles for randomized controlled trials (RCTs) and propensity score-matched observational studies. Two investigators independently rated the risk of bias of included studies and determined the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). If data permitted, we performed meta-analyses using random- and fixed-effects models.ResultsOut of 7755 citations, we included six RCTs (5862 patients) and 13 observational studies (6376 patients). In meta-analyses, patients treated with SAVR or TAVI had similar risks for mortality at 30 days (relative risk [RR] 1.05; 95% confidence interval [CI] 0.82 to 1.33) and 1 year (RR 1.02; 95% CI 0.93 to 1.13). TAVI had significantly lower risks for major bleeding but increased risks for major vascular complications, moderate or severe paravalvular aortic regurgitation, and new pacemaker implantation compared to SAVR. Comparing TAVI to medical therapy, mortality did not differ at 30 days but was significantly reduced at 1 year (RR 0.51; 95% CI 0.34 to 0.77).ConclusionsGiven similar mortality risks but different patterns of adverse events, the choice between TAVI and SAVR remains an individual one.

Balloon sizing during transcatheter aortic valve implantation

Although balloon sizing has been found to be useful during transcatheter aortic valve implantation (TAVI), its effectiveness in patients with bicuspid aortic valve (BiAV) remains unknown. Patients who underwent balloon sizing were retrospectively identified. The study comprised 67patients (61.2% with BiAV). Preprocedural hypothetical transcatheter heart valve (THV) sizing was based on multislice computed tomography (MSCT) measurements at the annulus. Changes in valve size after balloon sizing were reviewed. Postprocedural MSCT measurements and the grade of paravalvular aortic regurgitation (PAR) were compared. When comparing patients with aBiAV and those with atricuspid aortic valve (TiAV), there was no significant difference (p = 0.97) in the proportion of decreased (43.9% vs. 46.2%), unchanged (51.2% vs. 50.0%), or increased (4.9% vs. 3.8%) valve sizes chosen on the basis of MSCT findings. The anticipated annular sizing ratio for patients who received asmaller valve was 7.2% (3.5-10.5%) while it was 15.7% (12.5-19.0) for the others (p < 0.01), and no significant difference in the proportion of mild (or more severe) PAR cases was found between the groups (37.9% vs. 30.6%, p = 0.53 at the 1‑month follow-up). Stent frame expansion and eccentricity index were comparable between the BiAV and TiAV subgroups among patients who received asmaller THV after balloon sizing. Balloon sizing is auseful tool that is complementary to the current gold standard of MSCT for THV size selection as well as for BiAV morphology assessment.

Evaluation of Imaging Strategy to Optimize and Improve Outcome of Transcatheter Aortic Valvular Implantation

Cardiac computed tomography (CT) provides additional information with ultrasound in the transcatheter heart valve (THV) size selection. However, the influence of these incremental data on outcomes has not been evaluated in a randomized study. A single-center prospective, randomized, and open study was performed. Patients referred for transfemoral transcatheter aortic valve implantation with a balloon-expandable endoprothesis were included. THV size selection was performed using either transthoracic and transesophageal echocardiography data (control group) or ultrasound and CT results (CT group). The primary composite end point included the occurrence of stroke, major vascular complications, and moderate or severe paravalvular aortic regurgitation (PAR) at 1 year. Fifty patients (n = 25 in the control and CT groups) were enrolled. The primary composite end point occurred in 40% and 8% of patients from the control and CT groups, respectively (p = 0.008). The Kaplan-Meier analysis revealed a pejorative association with not performing the CT (p = 0.007). A decrease in the occurrence of PAR was observed in the CT group compared with the control group (PAR 28% vs 4%, p = 0.04; major vascular complications 12% vs 4%, p = 0.6; all-cause death 16% vs. 4%, p = 0.34; no stroke). In conclusion, the use of cardiac CT in addition to ultrasound data in THV size selection reduced the long-term occurrence of cardiovascular events.

TCTAP C-286 Successful Valve-in-Valve Implantation for Symptomatic Severe Paravalvular Aortic Regurgitation at Follow-up after Transcatheter Aortic Valve Replacement

TCTAP C-286 Successful Valve-in-Valve Implantation for Symptomatic Severe Paravalvular Aortic Regurgitation at Follow-up after Transcatheter Aortic Valve Replacement

Czech TAVI registry – Hospital outcome

The first TAVI in the Czech Republic was performed in 2008 and since then, more than 90% of TAVI procedures have been involved in the online all comers Czech TAVI Registry. 1532 TAVI procedures from 2008 till June 2016 in a high risk population with symptomatic severe aortic stenosis (logistic EuroSCORE 18.2, median age 80 years) were relatively safe (in-hospital mortality 3.9%, severe paravalvular aortic regurgitation after TAVI 1.0%) and highly effective (index of aortic valve area before versus after TAVI was 0.4cm2/m2 versus 1.0cm2/m2, respectively). Majority of patients (83.7%) underwent TAVI because of their high risk for surgery assessed by the Heart team discussion and 71.9% of them were discharged home.

Relationship of Annular Sizing Using Multidetector Computed Tomographic Imaging and Clinical Outcomes After Self-Expanding CoreValve Transcatheter Aortic Valve Replacement.

Multidetector computed tomography is useful for determining the appropriate transcatheter heart valve (THV) size in patients with severe aortic stenosis who are suboptimal surgical candidates. The relationship between adherence to the recommended CoreValve sizing algorithm and clinical outcomes is not known. We evaluated 1023 patients with severe aortic stenosis deemed high or extreme risk for surgery treated with the CoreValve THV. All patients underwent preprocedural multidetector computed tomography, and the scans were reviewed at a central analysis center using standardized software. Compliance to a recommended sizing algorithm was used to identify patients with below-range, in-range, and above-range THV sizing. A device annular sizing ratio (DAR) was also calculated based on the native annulus perimeter and perimeter of the selected THV. Clinical end points included the presence of paravalvular aortic regurgitation evaluated by an independent echocardiographic laboratory. Adherence to the sizing algorithm was highest with a 31-mm THV (92.6%) and lowest with the 23-mm THV (38.5%). Below-range sizing was associated with a higher rate of moderate or severe paravalvular aortic regurgitation (15.3%) than in-range (6.5%) or above-range (10.0%; P<0.001) sizing. Higher DARs were associated with lower rates of moderate or severe paravalvular aortic regurgitation: DAR ≤10%, 17.6%; DAR 10% to 15%, 9.9%; DAR 15% to 20%, 6.3%; and DAR >20%, 4.9%; P<0.001. There was no increase in clinical events associated with higher DARs. Adherence to a sizing algorithm guided by multidetector computed tomography resulted in lower rates of paravalvular aortic regurgitation after self-expanding transcatheter valve replacement without an increase in complications. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240902.

0354: Paravalvular aortic regurgitations with SAPIEN 3 prosthesis lowest seen with balloon-expandable TAVR

Paravalvular aortic regurgitation (PAR) after TAVR has been associated with increased mortality. The Sapien 3 device (Edwards Life-sciences) is different than the prior devices released by the same manufacturer in that it has a skirt designed to prevent paravalvular leak, improved coaxial alignment, and more accurate positioning. To evaluate paravalvular aortic regurgitations after 30-day after TAVI using the Edwards SAPIEN 3 prosthesis. Prospective monocentric study including 66 high-risk or non-operable patients with severe aortic stenosis undergoing TAVI using Edwards SAPIEN 3 prosthesis via transfemoral access, between September 2014 and March 2015. Mean age of patient was 84±7,1 years (70% female). The MDCT estimated an aortic annular diameter 25,07±2mm. Mean logistic EuroSCORE was 15,8±10,8. In our study, the device success rate was 98.5%. The pros-thesis has been deployed correctly in all cases and no failure of valve or embolization had occurred. Post TAVR, mean transaortic gradient decreased from 46,0±12,33mmHg to 8,2±3,37mmHg (p<0.001). No patient had moderate or severe PAR. At 30 days follow up, transthoracic echocardiography (TTE) showed that the PAR was absent or trivial in 66% of patients and mild in the remainder. Possible reasons for this low PAR rate include: 1) the outer polyethylene terephthalate sealing cuff, which enhances paravalvular sealing; 2) more accurate positioning; and 3) improved sizing with adjunctive MDCT. In our study, TAVI with Edwards SAPIEN 3 demonstrated lower paravalvular aortic leak rates than earlier generation devices in patients at high risk for surgery.

Resolution of severe hemolysis and paravalvular aortic regurgitation employing an Amplatzer Vascular Plug 4: the importance of detailed pre-procedural planning using CT angiography

A 76-year-old woman presented with progressive heart failure and transfusion-dependent hemolytic anemia due to severe paravalvular aortic regurgitation 4 years after bioprosthetic aortic valve replacement. She was deemed not to be a candidate for redo cardiac surgery due to a porcelain aorta and multiple comorbid medical conditions. We describe the role of pre-procedure contrast-enhanced, ECG-gated computed tomographic angiography to characterize the anatomy of the paravalvular leak connection for appropriate occluder device selection leading to successful percutaneous closure and resolution of the paravalvular regurgitation and hemolytic anemia.

Value of CMR in quantification of paravalvular aortic regurgitation after TAVI.

To assess the value of cardiac magnetic resonance (CMR) using phase-contrast velocity mapping for paravalvular aortic regurgitation (PAR) quantification. All patients undergoing transcatheter aortic valve implantation (TAVI) in our centre between November 2012 and August 2013, without CMR-contraindication were included. PAR severity was assessed 5 days after TAVI using: transthoracic echocardiography (TTE) and CMR [regurgitant volume (RV), regurgitant fraction (RF)]. Aortic regurgitation (AR) index was obtained during TAVI. Thirty of 51 patients who underwent TAVI were included (COREVALVE, n = 10; or EDWARDS SAPIEN XT, n = 20). At TTE, PAR was mild in 22, moderate in 3, and severe in 5 patients. Reliable phase-contrast images were acquired at the sino-tubular junction for SAPIEN and at the tubular portion of the ascending aorta for COREVALVE. The reproducibility of CMR was high (coefficient of correlation = 0.99 for intra- and inter-operator variability). At CMR, RV, and RF were significantly (P < 0.0005) correlated with AR severity at TTE, with mean RF values at 9.2 ± 7.6% in mild, 20.3 ± 4.2% in moderate, and 46.8 ± 10.8% in severe PAR. A cut-off value of RF < 14% at CMR accurately discriminated mild from moderate/severe (sensitivity: 100%, specificity: 82%). The mean AR index was 29.4 ± 6 for mild and 13.8 ± 5 for moderate/severe PAR. Three patients had a RF > 14% and a low AR index <25 despite a mild PAR at TTE, suggesting an underestimation at TTE. CMR is a reproducible, accurate, and reliable method to assess PAR severity. CMR may allow correcting an underestimation at TTE when AR index is doubtful.

Assessment of Paravalvular Aortic Regurgitation after Transcatheter Aortic Valve Replacement: Intra–Core Laboratory Variability

There is significant disparity in the reported incidence of moderate and severe paravalvular aortic regurgitation (PAR) between the Placement of Aortic Transcatheter Valves (PARTNER) I and PARTNER II trials, which may be related to the echocardiographic methodologies used by separate core laboratories. To further explore the variability in echocardiographic interpretation of PAR, agreement between the grading of PAR by the core laboratory of PARTNER IIB was compared with that by a consortium of echocardiography core laboratory directors. The PARTNER IIB core laboratory reevaluated patients using primarily the circumferential extent of the regurgitant jet for PAR. A consortium of echocardiography core laboratory directors was formed to evaluate the echocardiographic images and to grade PAR and central and total aortic regurgitation in a randomly chosen subset of the randomized patients in the PARTNER IIB trial using a multiwindow, multiparametric approach. Both a four-class scale (none or trace, mild, moderate, and severe) and a seven-class (none, trace, mild, mild to moderate, moderate, moderate to severe, and severe) scale were used. Levels of grading agreement between the consortium and original core laboratory in both scales were determined using weighted κ statistics. Only 87 patients assessed for PAR by the consortium could be paired with readings by the PARTNER IIB core laboratory. Using the four-class grading scheme the weighted κ statistic for PAR was 0.481 (95% confidence limits, 0.367, 0.595). Using the seven-class scale, the weighted κ statistic for PAR was 0.517 (95% confidence limits, 0.431, 0.607). For either grading scheme, 15.9% of patients graded by the PARTNER IIB core laboratory as having moderate PAR would have been graded as having mild PAR using the multiparametric approach. Similar results were seen for central and total aortic regurgitation assessments. Using primarily the circumferential extent criteria, the PARTNER IIB core laboratory overestimated the severity of PAR compared to the consortium using a multi-parametric approach. Although a more granular classification scheme for PAR may slightly improve concordance between core laboratories, differences in the incidence of moderate or severe PAR are likely related to differences in grading methodology. A multiparametric approach is advocated, and other echocardiographic methods for assessing PAR deserve further study.

TCT-744 Does “High” implantation Of Self-Expandable prosthesis Affect Positively Short- And Long-Term Outcome Of Patients Undergoing Transcatheter Aortic Valve Implantation?

Transcatheter aortic valve implantation (TAVI) is an emerging treatment option for inoperable or high risk patients. Low implantation (over 8mm) has been frequently implicated with moderate or severe paravalvular aortic regurgitation (PVR). However, it has not been evaluated the effect of high

Transcatheter Aortic Valve Replacement Using a Self-Expanding Bioprosthesis in Patients With Severe Aortic Stenosis at Extreme Risk for Surgery

This study sought to evaluate the safety and efficacy of the CoreValve transcatheter heart valve (THV) for the treatment of severe aortic stenosis in patients at extreme risk for surgery. Untreated severe aortic stenosis is a progressive disease with a poor prognosis. Transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis is a potentially effective therapy. We performed a prospective, multicenter, nonrandomized investigation evaluating the safety and efficacy of self-expanding TAVR in patients with symptomatic severe aortic stenosis with prohibitive risks for surgery. The primary endpoint was a composite of all-cause mortality or major stroke at 12 months, which was compared with a pre-specified objective performance goal (OPG). A total of 41 sites in the United States recruited 506 patients, of whom 489 underwent attempted treatment with the CoreValve THV. The rate of all-cause mortality or major stroke at 12 months was 26.0% (upper 2-sided 95% confidence bound: 29.9%) versus 43.0% with the OPG (p < 0.0001). Individual 30-day and 12-month events included all-cause mortality (8.4% and 24.3%, respectively) and major stroke (2.3% and 4.3%, respectively). Procedural events at 30 days included life-threatening/disabling bleeding (12.7%), major vascular complications (8.2%), and need for permanent pacemaker placement (21.6%). The frequency of moderate or severe paravalvular aortic regurgitation was lower 12 months after self-expanding TAVR (4.2%) than at discharge (10.7%; p = 0.004 for paired analysis). TAVR with a self-expanding bioprosthesis was safe and effective in patients with symptomatic severe aortic stenosis at prohibitive risk for surgical valve replacement. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement; NCT01240902).

Relative amplitude index: A new tool for hemodynamic evaluation of periprosthetic regurgitation after transcatheter valve implantation

The impact of paravalvular aortic regurgitation (PAR) on hemodynamic performance after transcatheter aortic valve implantation (TAVI) remains disputable. Common parameters such as the diastolic blood pressure or the blood pressure amplitude do not provide reproducible results. The aim of our study was to evaluate the impact of PAR on hemodynamics and outcome using the relative amplitude index (RAI). PAR was prospectively evaluated by echocardiography before discharge in 110 patients. The RAI was calculated according to the formula: RAI=[(Post-TAVI BP amplitude)/(Post-TAVI SBP) - (Pre-TAVI BP amplitude)/(Pre-TAVI SBP)]×100%, where BP is blood pressure and SBP is systolic blood pressure. Correlations of increased RAI with perioperative outcome were investigated and factors influencing mortality were isolated. The incidence of moderate and severe PAR after TAVI was 9% and 1%, respectively. Diastolic pressure or post-TAVI amplitude did not correlate to perioperative outcome. RAI increased from 2 when PAR was <2+ to 7 when PAR was ≥2+ (P=.006). A cut-off value of RAI ≥14 was associated with increased perioperative mortality (29 vs 5%; P=.013) and acute renal injury requiring dialysis (71 vs 18%; P=.001). RAI ≥14 was also associated with higher follow-up mortality at 1 year (57 vs 16%; P=.007). RAI ≥14 (odds ratio [OR], 3.390; 95% confidence interval [CI], 1.6-7.194; P=.00146), PAR ≥2+ (OR, 4.717; 95% CI, 1.828-12.195; P=.00135), and perioperative renal replacement therapy (OR, 12.820; 95% CI, 5.181-31.250; P=.00031) were found to be independent predictors of mortality at 1 year. The RAI is a useful tool to predict perioperative and 1-year outcome in patients with PAR after TAVI.

Análise da incidência e preditores clínicos e ecocardiográficos do refluxo paraprotético aórtico após o implante de prótese aórtica transcateter

BACKGROUND: The incidence of paravalvular aortic regurgitation (PAR) seems higher among patients submitted to transcatheter aortic valve implantation and its potential association with an increased late mortality has raised concerns in the scientific community. Our objective was to evaluate the incidence and clinical impact of PAR and establish PAR predictors in our patient population. METHODS: Between July/2009 and February/2013, 112 patients were submitted to transcatheter aortic valve implantation. The degree of PAR after the procedure was assessed according to the VARC 2 criteria. The population was divided into no/mild PAR group and moderate/severe PAR group. RESULTS: Mean age was 82.5 ± 3.9 years, 58.9% were female and the logistic EuroSCORE was 23.6 ± 13.4. There was a decrease in the mean systolic gradient (54.7 ± 15.3 mmHg vs 11.7 ± 4 mmHg; P < 0.01) and a gain in the aortic valve area (0.66 ± 0.15 cm2 vs 1.8 ± 0.3 cm2; P < 0.01). At the end of the procedure 46.4% did not have PAR, and mild or moderate PAR was observed in 42% and 11.6% of the patients. No patient presented severe PAR. Multivariate analysis identified male gender [odds ratio (OR) 5.85, confidence interval (CI] 1.29-26.7; P = 0.022), previous percutaneous aortic val­vuloplasty (OR 18.44, CI 2.30-147.85; P = 0.006), ejection fraction < 35% (OR 4.160, CI 1.014-17.064; P = 0.048) and the presence of severe pulmonary hypertension (OR 7.649, CI 1.86-31.51; P = 0.005) as independent predictors of moderate/severe PAR. CONCLUSIONS: The incidence of moderate/severe PAR was low and comparable to other studies. Male gender, history of prior percutaneous aortic valvuloplasty, presence of severe pulmonary hypertension and severe left ventricular dysfunction were independent predictors of this complication.

Real-Time Three-Dimensional Transesophageal Echocardiography Adds Value to Transcatheter Aortic Valve Implantation

Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. Procedural success was achieved in 99% of 256 patients (mean age, 82.9 ± 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 ± 11.2%; mean aortic valve area, 0.63 ± 0.19 cm(2)), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 ± 1.9 mm, 22.5 ± 2.2 mm (P < .001), and 23.0 ± 2.0 mm (P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.