Review

Update on the significance of postprocedural aortic regurgitation after transcatheter aortic valve replacement on postprocedural prognosis

Maximilian Schmidt-Salzmann

Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany

Search for more papers by this author

Michael Schlüter

Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany

Search for more papers by this author

Karl-Heinz Kuck

Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany

Search for more papers by this author

Christian Frerker

*Author for correspondence: Tel.: +49 4018 1885 2305; Fax: +49 4018 1885 4444;

E-mail Address: c.frerker@asklepios.com

Department of Cardiology, Asklepios Klinik St Georg, Hamburg, Germany

Search for more papers by this author

Published Online:23 Aug 2017https://doi.org/10.2217/fca-2017-0035

View article

Abstract

Transcatheter aortic valve replacement (TAVR) is an established therapy for patients with aortic stenosis and a high surgical risk. Recent data on intermediate-risk patients will probably enlarge the indication for TAVR. In the beginning of the TAVR era, relevant (>mild) aortic regurgitation (AR) was a common finding after TAVR; it was associated with worse outcome compared with patients without significant AR. To date, several improvements in imaging, grading of severity and treatment have been done and will be discussed in this article. AR after TAVR still is a strong and independent predictor of 1-year mortality and every effort should be made to prohibit its development.

Keywords:

Papers of special note have been highlighted as: • of interest; •• of considerable interest

References

1 Turina J, Hess O, Sepulcri F, Krayenbuehl HP. Spontaneous course of aortic valve disease. Eur. Heart J. 8(5), 471–483 (1987).Crossref, Medline, CAS, Google Scholar
2 Schwarz F, Baumann P, Manthey J et al. The effect of aortic valve replacement on survival. Circulation 66(5), 1105–1110 (1982).Crossref, Medline, CAS, Google Scholar
3 Murphy E, Lawson R, Starr A, Rhimtoola S. Severe aortic stenosis in patients 60 years of age or older : left ventricular function and 10-year survival after valve. Circulation 64, 184–188 (1981).Google Scholar
4 Siontis GCM, Praz F, Pilgrim T et al. Transcatheter aortic valve implantation vs surgical aortic valve replacement for treatment of severe aortic stenosis: a meta-analysis of randomized trials. Eur. Heart J. 37(47), 3503–3512 (2016).Crossref, Medline, Google Scholar
5 Iung B, Baron G, Butchart EG et al. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on valvular heart disease. Eur. Heart J. 24(13), 1231–1243 (2003).Crossref, Medline, Google Scholar
6 Leon MB, Smith CR, Mack M et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N. Engl. J. Med. 363(17), 1597–1607 (2010). • Shows noninferiority of transcatheter aortic valve replacement (TAVR; SAPIEN XT®) compared with surgical aortic valve replacement in patients with intermediate risk for surgery. This finding will probably enlarge the indication for TAVR in the near future.Crossref, Medline, CAS, Google Scholar
7 Smith CR, Leon MB, Mack MJ et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N. Engl. J. Med. 364(23), 2187–2198 (2011).Crossref, Medline, CAS, Google Scholar
8 Leon MB, Smith CR, Mack MJ et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N. Engl. J. Med. 374(17), 1609–1620 (2016).Crossref, Medline, CAS, Google Scholar
9 Reardon MJ, Van Mieghem NM, Popma JJ et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N. Engl. J. Med. 376(14), 1321–1331 (2017). • In addition to the aforegoing annotation, for the self-expanding CoreValve® and Evolut R® from Medtronic noninferiority compared with surgery was observed in patients with intermediate risk for surgery.Crossref, Medline, Google Scholar
10 Van Belle E, Juthier F, Susen S et al. Postprocedural aortic regurgitation in balloon-expandable and self-expandable transcatheter aortic valve replacement procedures: analysis of predictors and impact on long-term mortality: insights from the France2 registry. Circulation 129(13), 1415–1427 (2014).Crossref, Medline, Google Scholar
11 Abdel-Wahab M, Comberg T, Büttner HJ et al. Aortic regurgitation after transcatheter aortic valve implantation with balloon- and self-expandable prostheses: a pooled analysis from a 2-center experience. JACC Cardiovasc. Interv. 7(3), 284–292 (2014).Crossref, Medline, Google Scholar
12 Kodali S, Pibarot P, Douglas PS et al. Paravalvular regurgitation after transcatheter aortic valve replacement with the Edwards sapien valve in the PARTNER trial: characterizing patients and impact on outcomes. Eur. Heart J. 36(7), 449–456 (2015).Crossref, Medline, Google Scholar
13 Ewe SH, Muratori M, van der Kley F et al. Effect of aortic regurgitation following transcatheter aortic valve implantation on outcomes. Am. J. Cardiol. 115(5), 664–669 (2015).Crossref, Medline, Google Scholar
14 Collas VM, Paelinck BP, Rodrigus IE, Vrints CJ, Bosmans JM. Aortic regurgitation after transcatheter aortic valve implantation (TAVI) – angiographic, echocardiographic and hemodynamic assessment in relation to one year outcome. Int. J. Cardiol. 194, 13–20 (2015).Crossref, Medline, Google Scholar
15 Hayashida K, Lefèvre T, Chevalier B et al. Impact of post-procedural aortic regurgitation on mortality after transcatheter aortic valve implantation. JACC Cardiovasc. Interv. 5(12), 1247–1256 (2012).Crossref, Medline, Google Scholar
16 Shibayama K, Mihara H, Jilaihawi H et al. 3D Assessment of Features Associated With Transvalvular Aortic Regurgitation After TAVR: A Real-Time 3D TEE Study. JACC Cardiovasc. Imaging 9(2), 114–123 (2016).Crossref, Medline, Google Scholar
17 Hahn RT, Pibarot P, Weissman NJ, Rodriguez L, Jaber WA. Assessment of paravalvular aortic regurgitation after transcatheter aortic valve replacement: Intra-core laboratory variability. J. Am. Soc. Echocardiogr. 28(4), 415–422 (2015).Crossref, Medline, Google Scholar
18 Kiramijyan S, Magalhaes MA, Koifman E et al. Aortic regurgitation in patients undergoing transcatheter aortic valve replacement with the self-expanding corevalve versus the balloon-expandable SAPIEN XT valve. Am. J. Cardiol. 117(9), 1502–1510 (2016). • Shows that in experienced investigators using optimal intraprocedural strategies to prevent or immediately treat paravalvular aortic regurgitation (AR), there are no differences in incidence of paravalvular AR post-TAVR in self-expanding and balloon-expandable valves.Crossref, Medline, Google Scholar
19 Seiffert M, Fujita B, Avanesov M et al. Device landing zone calcification and its impact on residual regurgitation after transcatheter aortic valve implantation with different devices. Eur. Heart J. Cardiovasc. Imaging 17(5), 576–584 (2016).Crossref, Medline, Google Scholar
20 Jerez-Valero M, Urena M, Webb JG et al. Clinical impact of aortic regurgitation after transcatheter aortic valve replacement: Insights into the degree and acuteness of presentation. JACC Cardiovasc. Interv. 7(9), 1022–1032 (2014).Crossref, Medline, Google Scholar
21 Crouch G, Tully PJ, Bennetts J et al. Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement. J. Cardiovasc. Magn. Reson. 17, 32 (2015).Crossref, Medline, Google Scholar
22 Santos N, De Agustín JA, Almería C et al. Prosthesis/annulus discongruence assessed by three-dimensional transoesophageal echocardiography: A predictor of significant paravalvular aortic regurgitation after transcatheter aortic valve implantation. Eur. Heart J. Cardiovasc. Imaging 13(11), 931–937 (2012).Crossref, Medline, Google Scholar
23 Jilaihawi H, Kashif M, Fontana G et al. Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation. J. Am. Coll. Cardiol. 59(14), 1275–1286 (2012). • Since the results of this trial were published, 3D multidetector computed tomography is the gold standard for sizing before TAVR due to its superiority compared with echocardiography.Crossref, Medline, Google Scholar
24 Hansson NC, Thuesen L, Hjortdal VE et al. Three-dimensional multidetector computed tomography versus conventional 2-dimensional transesophageal echocardiography for annular sizing in transcatheter aortic valve replacement: influence on postprocedural paravalvular aortic regurgitation. Catheter. Cardiovasc. Interv. 82(6), 977–986 (2013).Crossref, Medline, Google Scholar
25 Willson AB, Webb JG, Labounty TM et al. 3-dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement: a multicenter retrospective analysis. J. Am. Coll. Cardiol. 59(14), 1287–1294 (2012). • Describes that oversizing of transcatheter heart valves leads to lower incidence of paravalvular AR post-TAVR.Crossref, Medline, Google Scholar
26 Ciobotaru V, Maupas E, Durrleman N et al. Predictive value for paravalvular regurgitation of 3-dimensional anatomic aortic annulus shape assessed by multidetector computed tomography post-transcatheter aortic valve replacement. Eur. Heart J. Cardiovasc. Imaging 17(1), 85–95 (2016).Medline, Google Scholar
27 Buellesfeld L, Stortecky S, Heg D et al. FD Extent and distribution of calcification of both the aortic annulus and the left ventricular outflow tract predict aortic regurgitation after transcatheter aortic valve replacement. EuroIntervention 10(6), 732–738 (2014).Crossref, Medline, Google Scholar
28 Masri A, Schoenhagen P, Svensson L et al. Dynamic characterization of aortic annulus geometry and morphology with multimodality imaging: Predictive value for aortic regurgitation after transcatheter aortic valve replacement. J. Thorac. Cardiovasc. Surg. 147(6), 1847–1854 (2014).Crossref, Medline, Google Scholar
29 Khalique OK, Hahn RT, Gada H et al. Quantity and location of aortic valve complex calcification predicts severity and location of paravalvular regurgitation and frequency of post-dilation after balloon-expandable transcatheter aortic valve replacement. JACC Cardiovasc. Interv. 7(8), 885–894 (2014).Crossref, Medline, Google Scholar
30 Azzalini L, Ghoshhajra BB, Elmariah S et al. The aortic valve calcium nodule score (AVCNS) independently predicts paravalvular regurgitation after transcatheter aortic valve replacement (TAVR). J. Cardiovasc. Comput. Tomogr. 8(2), 131–140 (2014).Crossref, Medline, Google Scholar
31 Mihara H, Shibayama K, Berdejo J et al. Impact of device landing zone calcification on paravalvular regurgitation after transcatheter aortic valve replacement: a real-time three-dimensional transesophageal echocardiographic study. J. Am. Soc. Echocardiogr. 28(4), 404–414 (2015).Crossref, Medline, Google Scholar
32 Gripari P, Ewe SH, Fusini L et al. Intraoperative 2D and 3D transoesophageal echocardiographic predictors of aortic regurgitation after transcatheter aortic valve implantation. Heart 98(16), 1229–1236 (2012).Crossref, Medline, Google Scholar
33 Buzzatti N, Maisano F, Latib A et al. Computed tomography-based evaluation of aortic annulus, prosthesis size and impact on early residual aortic regurgitation after transcatheter aortic valve implantation. Eur. J. Cardiothorac. Surg. 43(1), 43–50–51 (2013).Crossref, Google Scholar
34 Mylotte D, Lefevre T, Søndergaard L et al. Transcatheter aortic valve replacement in bicuspid aortic valve disease. J. Am. Coll. Cardiol. 64(22), 2330–2339 (2014).Crossref, Medline, Google Scholar
35 Perlman GY, Blanke P, Dvir D et al. Bicuspid aortic valve stenosis: favorable early outcomes with a next-generation transcatheter heart valve in a multicenter study. JACC Cardiovasc. Interv. 9(8), 817–824 (2016).Crossref, Medline, Google Scholar
36 Yang TH, Webb JG, Blanke P et al. Incidence and severity of paravalvular aortic regurgitation with multidetector computed tomography nominal area oversizing or undersizing after transcatheter heart valve replacement with the Sapien 3: a comparison with the SAPIEN XT. JACC Cardiovasc. Interv. 8(3), 462–471 (2015).Crossref, Medline, Google Scholar
37 Binder RK, Rodés-Cabau J, Wood DA, Webb JG. Edwards SAPIEN 3 valve. EuroIntervention 8(Suppl. Q), 83–87 (2012).Crossref, Medline, Google Scholar
38 Sinning JM, Werner N, Nickenig G, Grube E. Medtronic CoreValve Evolut valve. EuroIntervention 8(Suppl. Q), 94–96 (2012).Crossref, Medline, Google Scholar
39 Manoharan G, Walton AS, Brecker SJ et al. Treatment of symptomatic severe aortic stenosis with a novel resheathable supra-annular self-expanding transcatheter aortic valve system. JACC Cardiovasc. Interv. 8(10), 1359–1367 (2015).Crossref, Medline, Google Scholar
40 Manoharan G, Spence MS, Rodés-Cabau J, Webb JG. St Jude Medical Portico valve. EuroIntervention 8(Suppl. Q), 97–101 (2012).Crossref, Medline, Google Scholar
41 Meredith IT, Walters DL, Dumonteil N et al. 1-year outcomes with the fully repositionable and retrievable lotus transcatheter aortic replacement valve in 120 high-risk surgical patients with severe aortic stenosis: results of the REPRISE II study. JACC Cardiovasc. Interv. 9(4), 376–384 (2016).Crossref, Medline, Google Scholar
42 Meredith IT, Hood KL, Haratani N, Allocco DJ, Dawkins KD. Boston Scientific Lotus valve. EuroIntervention 8(Suppl. Q Figure 1), 70–74 (2012).Crossref, Google Scholar
43 Seiffert M, Conradi L, Kloth B et al. Single-centre experience with next-generation devices for transapical aortic valve implantation. Eur. J. Cardiothorac. Surg. 47(1), 39–45 (2015).Crossref, Medline, Google Scholar
44 Manoharan G, Linke A, Moellmann H et al. Multicentre clinical study evaluating a novel resheathable annular functioning self-expanding transcatheter aortic valve system: safety and performance results at 30 days with the Portico system. EuroIntervention 12(6), 768–774 (2016).Crossref, Medline, Google Scholar
45 Gonalves A, Almeria C, Marcos-Alberca P et al. Three-dimensional echocardiography in paravalvular aortic regurgitation assessment after transcatheter aortic valve implantation. J. Am. Soc. Echocardiogr. 25(1), 47–55 (2012).Crossref, Medline, Google Scholar
46 Altiok E, Frick M, Meyer CG et al. Comparison of two- and three-dimensional transthoracic echocardiography to cardiac magnetic resonance imaging for assessment of paravalvular regurgitation after transcatheter aortic valve implantation. Am. J. Cardiol. 113(11), 1859–1866 (2014). • The comparison of 2D echocardiography, 3D echocardiography and cardiac MRI in diagnostics of paravalvular post-TAVR showed superiority of MRI considering the latter as the gold standard. In addition, 3D echocardiography was superior to 2D echocardiography.Crossref, Medline, Google Scholar
47 Salaun E, Jacquier A, Theron A et al. Value of CMR in quantification of paravalvular aortic regurgitation after TAVI. Eur. Heart J. Cardiovasc. Imaging 17(1), 41–50 (2016).Medline, CAS, Google Scholar
48 Orwat S, Diller G-P, Kaleschke G et al. Aortic regurgitation severity after transcatheter aortic valve implantation is underestimated by echocardiography compared with MRI. Heart 100(24), 1933–1938 (2014).Crossref, Medline, Google Scholar
49 Sinning JM, Hammerstingl C, Vasa-Nicotera M et al. Aortic regurgitation index defines severity of peri-prosthetic regurgitation and predicts outcome in patients after transcatheter aortic valve implantation. J. Am. Coll. Cardiol. 59(13), 1134–1141 (2012).Crossref, Medline, Google Scholar
50 Jilaihawi H, Chakravarty T, Shiota T et al. Heart-rate adjustment of transcatheter haemodynamics improves the prognostic evaluation of paravalvular regurgitation after transcatheter aortic valve implantation. EuroIntervention 11(4), 456–464 (2015).Crossref, Medline, Google Scholar
51 Bugan B, Kapadia S, Svensson L, Krishnaswamy A, Tuzcu EM. Novel hemodynamic index for assessment of aortic regurgitation after transcatheter aortic valve replacement. Catheter. Cardiovasc. Interv. 86(3), E174–E179 (2015).Crossref, Medline, Google Scholar
52 Mihara H, Shibayama K, Jilaihawi H et al. Assessment of post-procedural aortic regurgitation after TAVR an intraprocedural TEE study. JACC Cardiovasc. Imaging 8(9), 993–1003 (2015).Crossref, Medline, Google Scholar
53 Kukucka M, Pasic M, Habazettl H et al. Contrast echocardiography: a novel technique for assessment of total aortic regurgitation following transapical aortic valve implantation. Eur. J. Cardiothorac. Surg. 47(1), 18–23 (2015).Crossref, Medline, Google Scholar
54 Kappetein AP, Head SJ, Généreux P et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation : the Valve Academic Research Consortium-2 consensus document. Eur. Heart J. 33, 2403–2418 (2012).Crossref, Medline, Google Scholar
55 Schultz CJ, Slots TLB, Yong G et al. An objective and reproducible method for quantification of aortic regurgitation after TAVI. EuroIntervention 10(3), 355–363 (2014).Crossref, Medline, Google Scholar
56 Tateishi H, Campos CM, Abdelghani M et al. Video densitometric assessment of aortic regurgitation after transcatheter aortic valve implantation: Results from the Brazilian TAVI registry. EuroIntervention 11(12), 1409–1418 (2016).Crossref, Medline, Google Scholar
57 Van Belle E, Rauch A, Vincent F et al. Von Willebrand factor multimers during transcatheter aortic-valve replacement. N. Engl. J. Med. 375(4), 335–344 (2016).Crossref, Medline, CAS, Google Scholar
58 Pibarot P, Hahn RT, Weissman NJ, Monaghan MJ. Assessment of paravalvular regurgitation following TAVR: a proposal of unifying grading scheme. JACC Cardiovasc. Imaging 8(3), 340–360 (2015).Crossref, Medline, Google Scholar
59 Bhatheja S, Panchal HB, Barry N, Mukherjee D, Uretsky BF, Paul T. Valvular performance and aortic regurgitation following transcatheter aortic valve replacement using Edwards valve versus CoreValve for severe aortic stenosis: a meta-analysis. Cardiovasc. Revascularization Med. 17(4), 248–255 (2016).Crossref, Google Scholar
60 Oh JK, Little SH, Abdelmoneim SS et al. Regression of Paravalvular Aortic Regurgitation and Remodeling of Self-Expanding Transcatheter Aortic Valve: An Observation from the CoreValve U.S. Pivotal Trial. JACC Cardiovasc. Imaging 8(12), 1364–1375 (2015).Crossref, Medline, Google Scholar
61 Chieffo A, Van Mieghem NM, Tchetche D et al. Impact of Mixed Aortic Valve Stenosis on VARC-2 Outcomes and Postprocedural Aortic Regurgitation in Patients Undergoing Transcatheter Aortic Valve Implantation. Catheter. Cardiovasc. Interv. 86(5), 875–885 (2015).Crossref, Medline, Google Scholar
62 Borz B, Durand E, Godin M et al. Does residual aortic regurgitation after transcatheter aortic valve implantation increase mortality in all patients? the importance of baseline natriuretic peptides. Int. J. Cardiol. 173(3), 436–440 (2014).Crossref, Medline, Google Scholar
63 Caballero L, Saura D, García-Lara J et al. Influence of aortic regurgitation after TAVI on left ventricular filling pattern. Eur. J. Clin. Invest. 45(1), 18–26 (2015).Crossref, Medline, Google Scholar
64 Poulin F, Carasso S, Horlick EM et al. Recovery of left ventricular mechanics after transcatheter aortic valve implantation: effects of baseline ventricular function and postprocedural aortic regurgitation. J. Am. Soc. Echocardiogr. 27(11), 1133–1142 (2014).Crossref, Medline, Google Scholar
65 Merten C, Beurich H-W, Zachow D et al. Aortic regurgitation and left ventricular remodeling after transcatheter aortic valve implantation: a serial cardiac magnetic resonance imaging study. Circ. Cardiovasc. Interv. 6(4), 476–483 (2013).Crossref, Medline, Google Scholar
66 Diemert P, Lange P, Greif M et al. Edwards SAPIEN XT valve placement as treatment option for aortic regurgitation after transfemoral CoreValve implantation: a multicenter experience. Clin. Res. Cardiol. 103(3), 183–190 (2014).Crossref, Medline, Google Scholar
67 Saia F, Martinez C, Gafoor S et al. Long-term outcomes of percutaneous paravalvular regurgitation closure after transcatheter aortic valve replacement: a multicenter experience. JACC Cardiovasc. Interv. 8(5), 681–688 (2015).Crossref, Medline, Google Scholar
68 Jochheim D, Zadrozny M, Theiss H et al. Aortic regurgitation with second versus third-generation balloon-expandable prostheses in patients undergoing transcatheter aortic valve implantation. EuroIntervention 11(2), 214–220 (2015).Crossref, Medline, Google Scholar

Vol. 13, No. 5

Metrics

Downloaded 40 times

History

Published online 23 August 2017

Published in print September 2017

Information

Keywords

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

PDF download