5‐Year outcomes after transcatheter aortic valve implantation: Focus on paravalvular leakage assessed by echocardiography and hemodynamic parameters

Abstract

Objectives We sought to assess the impact of echocardiographic and hemodynamic grading of paravalvular leakage (PVL) after transcatheter aortic valve implantation (TAVI) on the prediction of 5‐year mortality. PVL after TAVI is known to influence outcome after TAVI. Yet, present available data of long‐term outcomes and especially the comparison of different modalities for measurement of PVL is little. Methods We performed a retrospective single‐center cohort study and compared the prognostic value of echocardiographic PVL grading as well as the aortic regurgitation index (ARI) pre‐ and post‐TAVI. Univariable and multivariable Cox proportional regression analysis generated hazard ratios for mortality. Results A total of 464 patients underwent TAVI at our center between August 2012 and Decemebr 2014, with self‐expandable CoreValve (11%) or balloon‐expandable Sapien XT (47.4%) and Sapien 3 (41.6) valves. Overall 5‐year mortality was 52.4% (243/464). Echocardiographic classes of PVL at discharge showed a significant (p = 0.002) association with 5‐year mortality, mild PVL remained as an independent predictor for 5‐year mortality in multivariable analysis (hazard ratio: 1.642 [95% confidence interval: 1.235–2.182]; p = 0.001). Grades of PVL as assessed during the procedure by ARI (below the previously defined cut‐off of 25) did not show a significant association with 5‐year mortality (p = 0.417 and p = 0.995, respectively). Conclusions Even mild PVL assessed by echocardiography was an independent predictor for 5‐year survival, whereas hemodynamic measurements did not help to identify PVLs that are relevant to 5‐year survival.

Association between three-year mortality after transcatheter aortic valve implantation and paravalvular regurgitation graded by videodensitometry in comparison with visual grading

“…In addition to conventional angiography and echocardiography, haemodynamic assessment, such as aortic regurgitation index (ARI) [ 22 ], may be considered in relation to VD-AR. However, in our TAVI cohort neither ARI nor ARI ratio was predictive of mortality [ 18 ] and the same was true for the current subset (data not shown).…”

“…Based on the grading of aortic valve insufficiency according to Sellers et al [ 21 ], PVR is visually graded on angiography as “none/trace”, “mild”, “moderate” and “severe” [ 11 , 13 , 22 ]. Severe PVR requires immediate repair and there is ample evidence of increased mortality in patients left with moderate PVR after TAVI [ 5 , 6 , 9 , 12 , 13 , 18 ]. Yet, evidence on the prognostic impact of mild PVR is conflicting [ 6 , 9 , 12 , 13 , 18 ].…”

“…Severe PVR requires immediate repair and there is ample evidence of increased mortality in patients left with moderate PVR after TAVI [ 5 , 6 , 9 , 12 , 13 , 18 ]. Yet, evidence on the prognostic impact of mild PVR is conflicting [ 6 , 9 , 12 , 13 , 18 ]. This may be due in part to the subjective nature and substantial inter-observer variability of the visual grading of angiograms [ 10 , 14 , 20 ].…”

Determinants and treatments of heart failure after transcatheter aortic valve implantation: moving up a notch

“…Given this evidence, the incidence of significant PVL has been significantly reduced due to the development of prosthetic valve technology. However, recent reports have suggested that even mild PVL could be a determinant of worse midterm and long‐term outcomes following TAVI 80–82 . It is noteworthy that newer generation valves with a taller skirt could seal the bioprosthesis and reduce the severity of PVL 83 .…”

“…However, recent reports have suggested that even mild PVL could be a determinant of worse midterm and long-term outcomes following TAVI. [80][81][82] It is noteworthy that newer generation valves with a taller skirt could seal the bioprosthesis and reduce the severity of PVL. 83 Moreover, a recent report by Akodad et al demonstrated that late dilatation (a median of 4.6 months) for symptomatic transcatheter heart valve dysfunction reduced the transvalvular gradient and the PVL to less than or equal to mild in all cases with greater than mild PVL without inducing any complications.…”