Hemodynamic assessment of paravalvular aortic regurgitation after TAVI: estimated myocardial supply-demand ratio and cardiovascular mortality

Abstract

P. Hemodynamic assessment of paravalvular aortic regurgitation after TAVI: estimated myocardial supply-demand ratio and cardiovascular mortality. Am J Physiol Heart Circ Physiol 304: H1023-H1028, 2013. First published January 11, 2013; doi:10.1152/ajpheart.00807.2012.-A relevant (at least moderate) paravalvular regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) is found in up to 20% of cases and associated with increased mortality. The ratio of the diastolic over the systolic pressure time integral (DPTI:SPTI) has been proposed to reflect an estimate of myocardial oxygen supply versus demand and the propensity for myocardial ischemia. We have now evaluated the potential of this ratio to predict PAR-associated cardiovascular mortality after TAVI, retrospectively analyzing data from 167 consecutive TAVI patients. PAR was graded angiographically, and the myocardial supply-demand ratio was estimated from the planimetric integration of the diastolic and systolic pressure-time area (DPTI and SPTI), respectively. PAR was observed in 113 patients (67%) and angiographically graded as mild in 89 (78.8%), moderate in 21 (18.6%) or moderate to severe in 3 (2.7%) cases. The DPTI:SPTI ratio decreased with increasing Sellers grade of PAR (P Ͻ 0.001). A DPTI:SPTI of Յ0.7 predicted cardiovascular mortality (area under the curve ϭ 0.96). Cardiovascular mortality at 30 days and 1 yr was increased in patients with DPTI:SPTI Յ 0.7 over those with DPTI:SPTI Ͼ 0.7 (42 vs. 2% and 63 vs. 3%, respectively; P Ͻ 0.001). In conclusion, DPTI:SPTI provides an excellent cutoff value of Յ0.7 for the prediction of PAR-associated mortality. aortic regurgitation; aortic stenosis; transcatheter aortic valve implantation.THE INCIDENCE OF moderate and severe paravalvular aortic regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) varies from 10 to 20% (4,5,17,(21)(22)(23)27), and moderate-to-severe PAR after TAVI is associated with increased in-hospital mortality and unfavorable long-term outcome (1,11,14,20). PAR severity during TAVI is usually graded qualitatively using angiography. Quantitative evaluation of PAR has been recently proposed by use of the aortic regurgitation (AR) index, which is calculated as the ratio of the gradient between diastolic aortic pressure (DAP) and left ventricular (LV) end-diastolic pressure (LVEDP) to systolic blood pressure (SBP) ϫ 100 or [(DAP-LVEDP)/SBP] ϫ 100 (20) or more simply by use of the pressure difference between DAP and LVEDP (⌬P DAP-LVEDP ) (14). A pathophysiological understanding of PAR and its consequences is a prerequisite for an effective treatment and the improvement of survival.Myocardial ischemia is traditionally viewed as an imbalance of myocardial oxygen supply over demand. Such supplydemand ratio can be estimated from the ratio of the diastolic over systolic pressure time integral (DPTI:SPTI), which sensitively reflects the propensity to myocardial ischemia, notably subendocardial ischemia (7,8). Aortic regurgitation is typically associated with a reduce...

Hemodynamic classification of paravalvular leakage after transcatheter aortic valve implantation compared with angiographic or echocardiographic classification for prediction of 1‐year mortality

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Slope of left ventricular filling as an index of valvular and paravalvular regurgitation in native and prosthetic aortic valves

“…Among the quantitative hemodynamic indices that have been explored , AR and DPT indices have been applied, and demonstrated predictive of outcomes when certain thresholds (25 and 27.9, respectively) are not surpassed . Herein, we evaluated a new hemodynamic parameter of PAR after TAV, and can summarize our observations as follows: (1) LVDFS reliably correlates with severity of echocardiographic AR in patients with native aortic valve regurgitation as well as those post‐TAV, in which PAR is predominant; (2) LVDFS provides better statistical discrimination of AR grading than the AR index; and (3) LVDFS, unlike AR index, is reliable across a spectrum of heart rates.…”

Low Incidence of Paravalvular Leakage With the Balloon-Expandable Sapien 3 Transcatheter Heart Valve

“…However, because the native calcium deposits are displaced rather than removed, in contrast to conventional aortic valve replacement, paravalvular leakage might lead to more than clinically significant aortic valve regurgitation [11]. Recently, the presence of paravalvular leakage after transcatheter aortic valve replacement has been shown to be one of the major limitations in TAVR leading to unfavorable long-term outcomes [1,2]. Although some studies have shown no association between PVL and death [12,13], others have demonstrated that the presence of moderate or severe forms of PVL after TAVR adversely affects in-hospital and long-term survival [14][15][16].…”

“…The S3 THV shows a low incidence of postoperative aortic regurgitation, with 98% presenting with less than mild aortic regurgitation. T he occurrence of mild to severe paravalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) has been shown to be one of the major limitations in TAVR, causing an increased midterm and long-term mortality [1,2]. All strategies to decrease or even avoid the rate of PVL may then improve the patient's prognosis.…”