Does Minimalist Transcatheter Aortic Valve Replacement Miss Paravalvular Regurgitation? Incidence and Echocardiographic Distribution of "Missed" Paravalvular Regurgitation

Author Type(s)

Faculty

Document Type

Abstract

Publication Date

11-2021

Journal Title

Journal of the American College of Cardiology

Department

Surgery

Second Department

Medicine

Abstract

Background

With the transition to transthoracic echocardiography (TTE)-guided minimalist transcatheter aortic valve replacement (TAVR), paravalvular regurgitation (PVR) may be missed intraoperatively. We sought to determine the incidence and location of PVR that was missed intraoperatively but detected on predischarge (pre-DC) TTE.

Methods

From July 2015 to July 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist Sapien3 (Edwards) and Evolut (Medtronic) TAVR. PVR was defined as missed if pre-DC PVR was >1 grade higher than the corresponding intraoperative PVR grade. PVR was classified as anterior (10-2 o’clock) or posterior (4-8 o’clock) in parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C) views. The proportion of missed PVR was compared between the 8 locations, and the risk of missed PVR for each location was determined.

Results

Greater than mild PVR was seen in 55 (11.5%) cases intraoperatively and 91 (19.1%) at pre-DC, with no severe PVR. Among 91 cases with greater than mild pre-DC PVR, there were no significant differences in the incidence of anterior jets (PLAX: 35.2%, A3C: 22.0%, A5C: 30.8%, and PSAX: 40.7%) or posterior jets (PLAX: 35.2%, A3C: 45.1%, A5C: 56.0%, and PSAX: 33.0%), and PVR was missed in 42 (46.2%). The missed PVR rate was significantly higher for posterior jets (PLAX: 62.5%, A3C: 58.5%, A5C: 56.9%, and PSAX: 66.7%) compared with anterior jets (PLAX: 25%, A3C: 40%, A5C: 25%, and PSAX: 24.3%; all P < 0.05) (Figure 1). On logistic regression, all 4 posterior jet locations had a higher risk of missed PVR compared with the anterior PLAX jet (all P < 0.05).

Conclusion

Nearly half of greater than mild pre-DC PVR is missed or underestimated by >1 grade intraoperatively with TTE-guided minimalist TAVR, with greater risk of missing posterior jets. Transesophageal echocardiographic guidance may help minimize missing PVR. Further studies are warranted

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