The role of cardiovascular magnetic resonance in stratifying paravalvular leak severity after transcatheter aortic valve replacement: an observational outcome study

• Type of Material: Article
• Authors: Gregory R Hartlage, Emory University; Vasilis Babaliaros, Emory University; Vinod Thourani, Emory University; Salim Hayek, Emory University; Christina Chrysohoou, Emory University; Nima Ghasemzadeh, Emory University; Arthur Stillman, Emory University; Stephen Clements Jr., Emory University; John Oshinski, Emory University; Stamatios Lerakis, Emory University
• Language: English
• Date: 2014-12-05
• Publisher: BioMed Central
• Publication Version: Final Published Version
• Copyright Statement: © Hartlage et al.; licensee BioMed Central Ltd. 2014
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1186/s12968-014-0093-x
• Title of Journal or Parent Work: Journal of Cardiovascular Magnetic Resonance
• ISSN: 1097-6647
• Volume: 16
• Issue: 1
• Start Page: 93
• End Page: 93
• Keywords: Paravalvular regurgitation; Cardiovascular System & Cardiology; CONSENSUS DOCUMENT; Life Sciences & Biomedicine; Prognosis; Science & Technology; Radiology, Nuclear Medicine & Medical Imaging; Cardiac & Cardiovascular Systems; DISEASE; Transcatheter aortic valve implantation; TRANSTHORACIC ECHOCARDIOGRAPHY; IMPLANTATION; Cardiovascular magnetic resonance imaging; REGURGITATION

Abstract

BACKGROUND: Significant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis. Symptoms related to significant PVL may be difficult to differentiate from those related to other causes of heart failure. Cardiovascular magnetic resonance (CMR) directly quantifies valvular regurgitation, but has not been extensively studied in symptomatic post-TAVR patients. METHODS: CMR was compared to qualitative (QE) and semi-quantitative echocardiography (SQE) for classifying PVL and prognostic value at one year post-imaging in 23 symptomatic post-TAVR patients. The primary outcome was a composite of all-cause death, heart failure hospitalization, and intractable symptoms necessitating repeat invasive therapy; the secondary outcome was a composite of all-cause death and heart failure hospitalization. The difference in event-free survival according to greater than mild PVL versus mild or less PVL by QE, SQE, and CMR were evaluated by Kaplan-Meier survival analysis. RESULTS: Compared to QE, CMR reclassified PVL severity in 48% of patients, with most patients (31%) reclassified to at least one grade higher. Compared to SQE, CMR reclassified PVL severity in 57% of patients, all being reclassified to at least one grade lower; SQE overestimated PVL severity (mean grade 2.5 versus 1.7, p=0.001). The primary and secondary outcomes occurred in 48% and 35% of patients, respectively. Greater than mild PVL by CMR was associated with reduced event-free survival for the primary outcome (p<0.0001), however greater than mild PVL by QE and SQE were not (p=0.83 and p=0.068). Greater than mild PVL by CMR was associated with reduced event-free survival for the secondary outcome, as well (p=0.012). CONCLUSION: In symptomatic post-TAVR patients, CMR commonly reclassifies PVL grade compared with QE and SQE. CMR provides superior prognostic value compared to QE and SQE, as patients with greater than mild PVL by CMR (RF>20%) had a higher incidence of adverse events.