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Published in: Journal of Cardiovascular Magnetic Resonance 1/2015

Open Access 01-12-2015 | Research

Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement

Authors: Gareth Crouch, Phillip J Tully, Jayme Bennetts, Ajay Sinhal, Craig Bradbrook, Amy L Penhall, Carmine G De Pasquale, Robert A Baker, Joseph B Selvanayagam

Published in: Journal of Cardiovascular Magnetic Resonance | Issue 1/2015

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Abstract

Background

Paravalvular aortic regurgitation (PAR) following transcatheter aortic valve implantation (TAVI) is well acknowledged. Despite improvements, echocardiographic measurement of PAR largely remains qualitative. Cardiovascular magnetic resonance (CMR) directly quantifies AR with accuracy and reproducibility. We compared CMR and transthoracic echocardiography (TTE) analysis of pre-operative and post-operative aortic regurgitation in patients undergoing both TAVI and surgical aortic valve replacement (AVR).

Methods

Eighty-seven patients with severe aortic stenosis undergoing TAVI (56 patients) or AVR were recruited. CMR (1.5 T) and transthoracic echocardiography (TTE) were carried out pre-operatively and a median of 6 days post-operatively. The CMR protocol included regurgitant aortic flows using through-plane phase-contrast velocity. None/trivial, mild, moderate and severe AR by CMR was defined as ≤8%, 9-20%, 21–39%, >40% regurgitant fractions respectively.

Results

Pre- and post-operative left ventricular ejection fraction (LVEF) was similar. Post-procedure aortic regurgitant fraction using CMR was higher in the TAVI group (TAVI 16 ± 13% vs. AVR 4 ± 4%, p < 0.01). Comparing CMR to TTE, 27 of 56 (48%) TAVI patients had PAR which was at least one grade more severe on CMR than TTE (Z = −4.56, p <0.001). Sensitivity analysis confirmed the difference in PAR grade between TTE and CMR in the TAVI group (Z = −4.49, p < 0.001).

Conclusion

When compared to CMR based quantitative analysis, TTE underestimated the degree of paravalvular aortic regurgitation. This underestimation may in part explain the findings of increased mortality associated with mild or greater AR by TTE in the PARTNER trial. Paravalvular aortic regurgitation post TAVI assessed as mild by TTE may in fact be more severe.
Literature
1.
go back to reference Gotzmann M, Korten M, Bojara W, Lindstaedt M, Rahlmann P, Mugge A, et al. Long-term outcome of patients with moderate and severe prosthetic aortic valve regurgitation after transcatheter aortic valve implantation. Am J Cardiol. 2012;110:1500–6.CrossRefPubMed Gotzmann M, Korten M, Bojara W, Lindstaedt M, Rahlmann P, Mugge A, et al. Long-term outcome of patients with moderate and severe prosthetic aortic valve regurgitation after transcatheter aortic valve implantation. Am J Cardiol. 2012;110:1500–6.CrossRefPubMed
2.
go back to reference Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98.CrossRefPubMed Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98.CrossRefPubMed
3.
go back to reference Ussia GP, Barbanti M, Petronio AS, Tarantini G, Ettori F, Colombo A, et al. Transcatheter aortic valve implantation: 3-year outcomes of self-expanding CoreValve prosthesis. Eur Heart J. 2012;33:969–76.CrossRefPubMed Ussia GP, Barbanti M, Petronio AS, Tarantini G, Ettori F, Colombo A, et al. Transcatheter aortic valve implantation: 3-year outcomes of self-expanding CoreValve prosthesis. Eur Heart J. 2012;33:969–76.CrossRefPubMed
4.
go back to reference Vasa-Nicotera M, Sinning JM, Chin D, Lim TK, Spyt T, Jilaihawi H, et al. Impact of paravalvular leakage on outcome in patients after transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2012;5:858–65.CrossRefPubMed Vasa-Nicotera M, Sinning JM, Chin D, Lim TK, Spyt T, Jilaihawi H, et al. Impact of paravalvular leakage on outcome in patients after transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2012;5:858–65.CrossRefPubMed
5.
go back to reference Webb JG, Wood DA. Current status of transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;60:483–92.CrossRefPubMed Webb JG, Wood DA. Current status of transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;60:483–92.CrossRefPubMed
6.
go back to reference Kappetein AP, Head SJ, Genereux P, Piazza N, van Mieghem NM, Blackstone EH, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg. 2012;42:S45–60.CrossRefPubMed Kappetein AP, Head SJ, Genereux P, Piazza N, van Mieghem NM, Blackstone EH, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg. 2012;42:S45–60.CrossRefPubMed
7.
go back to reference Gelfand EV, Hughes S, Hauser TH, Yeon SB, Goepfert L, Kissinger KV, et al. Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson. 2006;8:503–7.CrossRefPubMed Gelfand EV, Hughes S, Hauser TH, Yeon SB, Goepfert L, Kissinger KV, et al. Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson. 2006;8:503–7.CrossRefPubMed
8.
go back to reference Globits S, Higgins CB. Assessment of valvular heart disease by magnetic resonance imaging. Am Heart J. 1995;129:369–81.CrossRefPubMed Globits S, Higgins CB. Assessment of valvular heart disease by magnetic resonance imaging. Am Heart J. 1995;129:369–81.CrossRefPubMed
9.
go back to reference Myerson SG, d’Arcy J, Mohiaddin R, Greenwood JP, Karamitsos TD, Francis JM, et al. Aortic regurgitation quantification using cardiovascular magnetic resonance: association with clinical outcome. Circulation. 2012;126:1452–60.CrossRefPubMed Myerson SG, d’Arcy J, Mohiaddin R, Greenwood JP, Karamitsos TD, Francis JM, et al. Aortic regurgitation quantification using cardiovascular magnetic resonance: association with clinical outcome. Circulation. 2012;126:1452–60.CrossRefPubMed
10.
go back to reference Sondergaard L, Lindvig K, Hildebrandt P, Thomsen C, Stahlberg F, Joen T, et al. Quantification of aortic regurgitation by magnetic resonance velocity mapping. Am Heart J. 1993;125:1081–90.CrossRefPubMed Sondergaard L, Lindvig K, Hildebrandt P, Thomsen C, Stahlberg F, Joen T, et al. Quantification of aortic regurgitation by magnetic resonance velocity mapping. Am Heart J. 1993;125:1081–90.CrossRefPubMed
11.
go back to reference Crouch G, Bennetts J, Sinhal A, Tully PJ, Leong DP, Bradbrook C, et al. Early effects of transcatheter aortic valve implantation and aortic valve replacement on myocardial function and aortic valve hemodynamics: Insights from cardiovascular magnetic resonance imaging. J Thorac Cardiovasc Surg. 2015;149(2):462–70 Crouch G, Bennetts J, Sinhal A, Tully PJ, Leong DP, Bradbrook C, et al. Early effects of transcatheter aortic valve implantation and aortic valve replacement on myocardial function and aortic valve hemodynamics: Insights from cardiovascular magnetic resonance imaging. J Thorac Cardiovasc Surg. 2015;149(2):462–70
12.
go back to reference Altiok E, Frick M, Meyer CG, Al Ateah G, Napp A, Kirschfink A, et al. Comparison of two- and three-dimensional transthoracic echocardiography to cardiac magnetic resonance imaging for assessment of paravalvular regurgitation after transcatheter aortic valve implantation. Am J Cardiol. 2014;113:1859–66.CrossRefPubMed Altiok E, Frick M, Meyer CG, Al Ateah G, Napp A, Kirschfink A, et al. Comparison of two- and three-dimensional transthoracic echocardiography to cardiac magnetic resonance imaging for assessment of paravalvular regurgitation after transcatheter aortic valve implantation. Am J Cardiol. 2014;113:1859–66.CrossRefPubMed
13.
go back to reference Hartlage GR, Babaliaros VC, Thourani VH, Hayek S, Chrysohoou C, Ghasemzadeh N, et al. The role of cardiovascular magnetic resonance in stratifying paravalvular leak severity after transcatheter aortic valve replacement: an observational outcome study. J Cardiovasc Magn Reson. 2014;16:93.CrossRefPubMedCentralPubMed Hartlage GR, Babaliaros VC, Thourani VH, Hayek S, Chrysohoou C, Ghasemzadeh N, et al. The role of cardiovascular magnetic resonance in stratifying paravalvular leak severity after transcatheter aortic valve replacement: an observational outcome study. J Cardiovasc Magn Reson. 2014;16:93.CrossRefPubMedCentralPubMed
14.
go back to reference Ribeiro HB, Le Ven F, Larose E, Dahou A, Nombela-Franco L, Urena M, et al. Cardiac magnetic resonance versus transthoracic echocardiography for the assessment and quantification of aortic regurgitation in patients undergoing transcatheter aortic valve implantation. Heart. 2014;100:1924–32.CrossRefPubMed Ribeiro HB, Le Ven F, Larose E, Dahou A, Nombela-Franco L, Urena M, et al. Cardiac magnetic resonance versus transthoracic echocardiography for the assessment and quantification of aortic regurgitation in patients undergoing transcatheter aortic valve implantation. Heart. 2014;100:1924–32.CrossRefPubMed
15.
go back to reference Gabriel RS, Renapurkar R, Bolen MA, Verhaert D, Leiber M, Flamm SD, et al. Comparison of severity of aortic regurgitation by cardiovascular magnetic resonance versus transthoracic echocardiography. Am J Cardiol. 2011;108:1014–20.CrossRefPubMed Gabriel RS, Renapurkar R, Bolen MA, Verhaert D, Leiber M, Flamm SD, et al. Comparison of severity of aortic regurgitation by cardiovascular magnetic resonance versus transthoracic echocardiography. Am J Cardiol. 2011;108:1014–20.CrossRefPubMed
16.
go back to reference Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2009;22:975–1014. quiz 1082.CrossRefPubMed Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2009;22:975–1014. quiz 1082.CrossRefPubMed
17.
go back to reference Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777–802.CrossRefPubMed Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777–802.CrossRefPubMed
18.
go back to reference Sherif MA, Abdel-Wahab M, Beurich HW, Stocker B, Zachow D, Geist V, et al. Haemodynamic evaluation of aortic regurgitation after transcatheter aortic valve implantation using cardiovascular magnetic resonance. EuroIntervention. 2011;7:57–63.CrossRefPubMed Sherif MA, Abdel-Wahab M, Beurich HW, Stocker B, Zachow D, Geist V, et al. Haemodynamic evaluation of aortic regurgitation after transcatheter aortic valve implantation using cardiovascular magnetic resonance. EuroIntervention. 2011;7:57–63.CrossRefPubMed
19.
go back to reference Genereux P, Cohen DJ, Mack M, Rodes-Cabau J, Yadav M, Xu K, et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol. 2014;64:2605–15.CrossRefPubMed Genereux P, Cohen DJ, Mack M, Rodes-Cabau J, Yadav M, Xu K, et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol. 2014;64:2605–15.CrossRefPubMed
20.
go back to reference Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–607.CrossRefPubMed Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–607.CrossRefPubMed
21.
go back to reference Gotzmann M, Pljakic A, Bojara W, Lindstaedt M, Ewers A, Germing A, et al. Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis-predictors of mortality and poor treatment response. Am Heart J. 2011;162:238–245.e1.CrossRefPubMed Gotzmann M, Pljakic A, Bojara W, Lindstaedt M, Ewers A, Germing A, et al. Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis-predictors of mortality and poor treatment response. Am Heart J. 2011;162:238–245.e1.CrossRefPubMed
22.
go back to reference Takagi K, Latib A, Al-Lamee R, Mussardo M, Montorfano M, Maisano F, et al. Predictors of moderate-to-severe paravalvular aortic regurgitation immediately after CoreValve implantation and the impact of postdilatation. Catheter Cardiovasc Interv. 2011;78:432–43.PubMed Takagi K, Latib A, Al-Lamee R, Mussardo M, Montorfano M, Maisano F, et al. Predictors of moderate-to-severe paravalvular aortic regurgitation immediately after CoreValve implantation and the impact of postdilatation. Catheter Cardiovasc Interv. 2011;78:432–43.PubMed
24.
go back to reference Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366:1686–95.CrossRefPubMed Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366:1686–95.CrossRefPubMed
Metadata
Title
Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement
Authors
Gareth Crouch
Phillip J Tully
Jayme Bennetts
Ajay Sinhal
Craig Bradbrook
Amy L Penhall
Carmine G De Pasquale
Robert A Baker
Joseph B Selvanayagam
Publication date
01-12-2015
Publisher
BioMed Central
Published in
Journal of Cardiovascular Magnetic Resonance / Issue 1/2015
Electronic ISSN: 1532-429X
DOI
https://doi.org/10.1186/s12968-015-0134-0

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