Perspective:

Assessment of PAR remains challenging on TEE during transcatheter aortic valve replacement (TAVR), as these jets are often complex and highly eccentric, and patterns of PAR may vary between different TAVR devices. Further, existing criteria for grading PAR have not been validated for TAVR devices, and the optimal method for grading PAR remains unclear. There are several key findings in this study. First, it observes that many measurement parameters cannot be obtained in all patients, reinforcing the need for combined assessment using multiple methods to grade PAR. Second, it finds that consistent HDFR or extent of the jet beyond the anterior mitral leaflet is independently associated with significant PAR, with a high specificity and moderate sensitivity. Identification of these two findings can be helpful to identify patients with PAR, although the low sensitivity suggests that these should not be used in isolation. Third, the optimal site for measurement of short-axis Doppler on TEE has been unclear, and a substudy in this manuscript provides supporting evidence that measurement of short-axis Doppler at the annulus level may be preferable over measurement at the bottom of the prosthesis. This manuscript may improve our ability to grade PAR with the balloon-expandable Edwards valve, although whether these findings apply to other TAVR devices is not clear.