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CMR to stratify post-TAVR paravalvular leak in patients with suboptimal echocardiography

Background

Despite extensive pre-procedure evaluation, greater than mild paravalvular leak (PVL) occurs in over 10% of patients undergoing transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes. Echocardiography, the standard method of imaging PVL, often has limited utility due to frequently multiple eccentric regurgitant jets. Acoustic shadowing from the valve stent and native aortic valve calcification may lead to further underestimation of PVL. Cardiovascular magnetic resonance (CMR) is considered the gold standard for quantification of valvular regurgitation. We evaluated the utility of CMR to grade PVL severity and predict outcomes in patients with suboptimal echocardiography.

Methods

Seventeen non-operative post-TAVR patients (NYHA class III-IV; age 84 ± 5 yrs) underwent CMR due to PVL and symptoms out of proportion to echocardiographic findings or suboptimal echocardiographic study. CMR was performed on a Siemens Avanto 1.5 T with velocity phase imaging in the ascending aorta for flow quantification. CMR PVL severity was graded by regurgitant fraction (RF; mild≤20%, moderate 21-39%, severe ≥40%). Short- and intermediate-term follow-up was conducted after CMR. Patients were followed-up for symptoms and a composite outcome of repeat invasive therapy, heart failure hospitalization, or death.

Results

CMR was performed as early as 2 days and as late as 35 months post-TAVR in both the inpatient (n = 9) and outpatient (n = 8) settings. PVL grading was mild in 11, moderate in 3, and severe in 3 patients. Compared to echocardiography, PVL severity was reclassified in 47% (5 upgraded to moderate or severe; 3 downgraded to mild). CMR findings guided further management in 71% (medical therapy including diuresis in 8 with mild or moderate PVL; invasive therapy including vascular plug closure or valve in valve deployment in 4 with moderate or severe PVL). At short-term follow-up (mean 1.7 ± 1.4 months), 76% had NYHA class improvement. At intermediate-term follow-up (mean 11.6 ± 1.0 months), 65% had persistent improvement in NYHA class (Table 1). At one year, 47% (n = 8) met the composite outcome. Outcome free survival was significantly better with ≤mild PVL compared to > mild PVL (73% vs 17%; p < 0.05). The mean RF was larger in those reaching the composite outcome compared to those not (24 ± 19% vs 11 ± 8%), with a trend towards significance (p = 0.08; Table 2). Patients undergoing repeat CMR after invasive PVL therapy (n = 3) demonstrated a reduction in mean RF from 43% to 12%.

Table 1 CMR clinical utility and follow-up symptoms.
Table 2 CMR PVL grading and prognosis.

Conclusions

CMR stratifies PVL severity in symptomatic patients with suboptimal echocardiography or discrepant results. CMR is useful in guidance of specific post procedure therapy and has prognostic importance, with greater than mild PVL (RF > 20%) associated significantly with worse outcomes.

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None.

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Correspondence to Gregory Hartlage.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Hartlage, G., Hayek, S., Babaliaros, V. et al. CMR to stratify post-TAVR paravalvular leak in patients with suboptimal echocardiography. J Cardiovasc Magn Reson 16, O102 (2014). https://doi.org/10.1186/1532-429X-16-S1-O102

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Keywords

  • Cardiovascular Magnetic Resonance
  • NYHA Class
  • Transcatheter Aortic Valve Replacement
  • Aortic Valve Calcification
  • Paravalvular Leak