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