Elsevier

International Journal of Cardiology

Volume 329, 15 April 2021, Pages 153-161
International Journal of Cardiology

The prognostic value of immediate post-TAVI hemodynamic evaluation is superior to aortography and transoesophageal echocardiography in predicting patient survival

https://doi.org/10.1016/j.ijcard.2020.12.058Get rights and content

Highlights

  • Paravalvular aortic regurgitation (PAR) is a major complication of TAVI.

  • Post-TAVI PAR has a negative impact on long-term survival of the patients.

  • Among 3 modalities that are generally used to evaluate post-TAVI PAR, RI shows the highest predictive value for survival.

  • Post-TAVI RI result is a significant predictor of survival and its effect is linear.

Abstract

Background

Although post-TAVI PAR is commonly seen, its exact evaluation, grading and the true impact on patients' survival are still debated. This single center study aimed to evaluate the effect of post transcatheter aortic valve implantation (TAVI) paravalvular aortic regurgitation (PAR) on patients' survival. The outcome was evaluated by the three most commonly used techniques just after TAVI in the interventional arena.

Methods

201 high risk patients with severe symptomatic aortic stenosis underwent TAVI with the self-expandable system. The severity of post-TAVI PAR was prospectively evaluated by aortography and transesophageal echocardiography (TEE) using a four-class scheme and hemodynamic evaluation by calculation of the regurgitation index (RI). Median follow up time was 763 days.

Results

Post-TAVI PAR results of the three different modalities were concordant with each other (all p < 0.001). Patients with grade 0-I PAR by aortography had better long term outcomes compared to those who had grade II-III PAR (unadjusted HR 1.77 [95% CI, 1.04–3.01], p = 0.03). Although in multivariate analysis neither aortography nor TEE were shown to be significant predictors of survival, hemodynamic assessment using the exact RI result was a significant predictor of survival and its effect was found to be linear (adjusted HR 0.72 [95% CI, 0.52–0.98] for 10% point increase in RI, p = 0.03595).

Conclusions

Among the three modalities that are frequently used to evaluate the outcome, post-TAVI RI showed the highest added predictive value for survival.

Introduction

Nowadays in case of severe symptomatic AS in high risk or surgically contraindicated patients, transcatheter aortic valve implantation (TAVI) is the treatment of choice [1]. In the last decade, TAVI has proved to be a feasible intervention with high procedural success rate and efficacy in the mid-long term. Despite the improvement in implantation techniques and valve design, the paravalvular aortic regurgitation (PAR) has remained a major concern. Trials have shown that significant post-TAVI PAR has a negative impact on patients' survival [2]. Numerous conditions have been proposed to lead to PAR after TAVI implantation, namely: heavy calcification described by the Agatston score [3], patient prosthesis mismatch and inappropriate implantation depth [4]. Post-TAVI PAR is observed in two-thirds of the cases and it is reported to be more than mild in 15–20% after TAVI [5]. In everyday practice, the assessment of aortography, echocardiography and hemodynamics are the most commonly used methods to evaluate PAR immediately after TAVI implantation in the interventional arena. Despite its frequency, post-TAVI PAR evaluation still represents a diagnostic challenge. PAR grading with aortography and echocardiography is ambiguous and the clinical impact is still debated. The need for result modification is usually decided by operators based on their local practice. Balloon post dilatation (BPD) is the most commonly used technique if PAR is considered clinically relevant. Other techniques like valve position modification with a snare catheter, second valve implantation or percutaneous paravalvular leak closure devices are also available options to reduce relevant post-TAVI PAR [6]. Till now data are scarce to guide the post-TAVI PAR management.

The aim of this prospective, observational single centre study is to compare the most widely used three modalities for the assessment of PAR severity in clinical practice, immediately after TAVI. We investigated the concordance of the modalities and the univariate and multivariate relationship of patient characteristics and their modalities with survival.

Section snippets

Patient population

201 consecutive elective elderly (mean age 80.4 ± 5.7 years) patients with severe, symptomatic native AS, and (extreme) high surgical risk (mean Society of Thoracic Surgeons Mortality Score was 4,2%, IQR: 2.9–6.0%) were included in our prospective observational study, from October 2014 until February 2019. The study was accepted by the local ethics committee, all patients had signed the informed consent form. All TAVI implantations were recommended by the local heart team and the procedures

Patients and procedures

In our single centre, observational study, 201 consecutive patients were treated with SE TAVI implantation. The procedural success rate was 100%. Median follow up time was 763 (lower-upper quartiles: 489–1179) days. In almost one-third of the cases (31%) BPD was performed. In 7 (3.5%) cases, a second valve was implanted. Characteristics of the patients and PAR results are summarized in Table 1. Procedural characteristics, technical details and clinical outcomes are shown in Table 2,

Discussion

In contrast to surgery, during TAVI, fluoroscopic guidance is used for valve deployment, therefore proper positing and sealing can be problematic. Thanks to the MSCTA based valve selection [15,16] and to the developing device portfolio, post-TAVI PAR seems to be decreasing [17], although post-TAVI-PAR is still a major concern [18]. Some data indicate that even mild PAR may be associated with impaired outcome [19]. Precise PAR evaluation after TAVI is important to improve patient outcome, but

Conclusions

Post-TAVI PAR assessment and consideration of any further treatment should be a comprehensive decision making process. We found that PAR evaluation by TEE showed no correlation with the long term survival. Post-TAVI aortographic PAR evaluation showed significant survival benefit when comparing patients with grade 0-I and grade II-III regurgitation but only in the univariate analysis. Hemodynamic assessment with RI was found to be an independent predictor of long term survival and it

Credit authorship contribution statement

Gabor Dekany: Conceptualization, Methodology, Validation, Data curation, Investigation, Writing - original draft, Visualization. Geza Fontos: Investigation, Supervision. Sai Satish: Investigation. Gergely Szabo: Resources. Tunde Pinter: Investigation. Zsolt Piroth: Investigation, Writing - review & editing. Marton Vertesaljai: Investigation. Matyas Pal: Investigation. Adrienn Mandzak: Project administration. Zalan Gulyas: Validation, Investigation. Sara Gharehdaghi: Writing - review & editing.

Declaration of Competing Interest

None.

Acknowledgements

Present study has not received any financial support or grant, etc.

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