Intraoperative 2D and 3D Transoesophageal Echocardiographic Predictors of Aortic Regurgitation After Transcatheter Aortic Valve Implantation

Study Questions:

Among patients undergoing transcatheter aortic valve implantation (TAVI), are there features of the native aortic valve on intraoperative two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) that are associated with significant postprocedural paravalvular aortic regurgitation (AR)?

Methods:

A cohort of 135 patients (81 ± 7 years) with severe symptomatic aortic stenosis (AS) undergoing TAVI using a SAPIEN valve at one of two centers were imaged with 2D and 3D TEE before and during the procedure. Baseline and periprocedural echocardiographic characteristics were tested to predict paravalvular AR post-TAVI: calcification at the aortic valve commissures and leaflets, “aortic annulus eccentricity index” (1 – [shortest dimension / longest dimension]), “area cover index” (1 – [annulus area / nominal device area when inflated]), and overlap between TAVI prosthesis and the anterior mitral leaflet. Postprocedural paravalvular AR ≥2 (defined as “mild-to-moderate”) was considered significant.

Results:

TAVI was performed in all patients. The incidence of paravalvular AR ≥2 immediately after the procedure was 21% (28 patients). Commissural calcification—and particularly calcification of the commissure between the right coronary and noncoronary cusps—was significantly more frequent among patients who developed paravalvular AR; and the pre-TAVI “area cover index” was significantly lower among patients with AR (11.1 ± 11.8% vs. 20.8 ± 12.5%, p = 0.0004). Multivariate analysis revealed that calcification of the commissure between the right coronary and noncoronary cusps (odds ratio [OR], 2.66; 95% confidence interval [CI], 1.39-5.12; p = 0.001), and the “area cover index” pre-TAVI (OR, 0.95; 95% CI, 0.91-0.99; p = 0.006) were the only independent predictors of significant paravalvular AR after TAVI.

Conclusions:

Intraoperative 2D and 3D TEE identified calcification of the commissure between the right coronary and noncoronary cusps and the “area cover index” (defined by the ratio of the aortic valve annulus area to the predicted cross-sectional area of the expanded TAVI) as independent predictors of significant paravalvular AR following TAVI.

Perspective:

Paraprosthetic AR following TAVI is of potential importance for two reasons. First, patients with longstanding isolated severe AS without AR before the procedure sometimes have poor hemodynamic tolerance of acute AR caused by the procedure, owing to what is typically a small, hypertrophied (noncompliant) left ventricle. Second, data suggest that patients with significant AR following TAVI have worse survival statistics compared to others who do not. The latter begs the question of whether it is the AR that increases mortality risk, or whether the presence of AR is a marker of other disease––most likely diffuse arterial calcification. This study confirms that dense and asymmetrical valve calcification, along with mismatch between the cross-sectional areas of the aortic valve annulus and of the device being deployed, portent a higher risk of postprocedural AR with this balloon-expandable device. It remains to be determined whether AR or the underlying calcification is of clinical pertinence.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Odds Ratio, Multivariate Analysis, Calcinosis, Angioplasty, Balloon, Coronary, Hemodynamics, Echocardiography, Three-Dimensional, Prostheses and Implants, Vascular Calcification, Confidence Intervals, Heart Ventricles, Echocardiography, Transesophageal, Mitral Valve


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