The dicrotic notch index (DNI) – a novel hemodynamic measure – may be used after transcatheter aortic valve replacement (TAVR) to identify patients with aortic regurgitation (AR), according to research presented May 21 at the Society for Cardiovascular Angiography and Interventions 2019 Scientific Sessions in Las Vegas and simultaneously published in JACC: Cardiovascular Interventions.

Divyanshu Mohananey, MD, et al., examined 204 patients with analyzable hemodynamic tracings undergoing TAVR between January 1, 2014 and April 31, 2016. DNI was defined as the difference of systolic blood pressure and dicrotic notch divided by the pulse pressure. For each measurement, the researchers obtained and analyzed offline angiographic tracings. Transfemoral access was obtained in 86.2 percent of patients, balloon post-dilation was done in 43 cases and a valve-in-valve was required in five cases.

Of the total patient group, 62 (30 percent) had no post-TAVR AR, 102 (50 percent) had trivial post-TAVR AR, 35 (17 percent) had mild post-TAVR AR and five (2.5 percent) had moderate post-TAVR AR. There was an increase in post-TAVR mean systolic blood pressure, diastolic blood pressure, dicrotic notch and DNI. Patients with hemodynamically significant AR had comparable systolic blood pressure, diastolic blood pressure and higher dicrotic notch pressure as compared to those without significant AR. There was a lower DNI in patients with hemodynamically significant AR. Researchers found that DNI had a good predictive value in detecting significant AR with an AUC of 0.8 (95 percent CI 0.69- 0.91, p=0.021) and that a cut-off of <0.63 provides a 100 percent sensitivity whereas a cut-off of <0.50 provides a 95.5 percent specificity for detecting hemodynamically significant AR.

The authors conclude that DNI may become an additional tool that, along with transthoracic echocardiogram, can help identify patients who require corrective measures such as balloon post-dilation, valve-in-valve or repositioning when possible. "While echocardiography after TAVR remains the gold standard for diagnosis of AR, hemodynamic measures such as the DNI allow for simple intra-procedural methods for identifying patients with AR," they write.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Transcatheter Aortic Valve Replacement, Aortic Valve Insufficiency, Blood Pressure, Dilatation, Area Under Curve, Aortic Valve, Heart Valve Prosthesis, Echocardiography, Systole, Angiography

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