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

Hartlage GR, Babaliaros VC, Thourani VH, Hayek S, Chrysohoou C, Ghasemzadeh N, Stillman AE, Clements SD, Oshinski JN, Lerakis S - J Cardiovasc Magn Reson (2014)

Bottom Line: 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).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.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Division of Cardiology, Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia. sleraki@emory.edu.

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.

Show MeSH

Related in: MedlinePlus

Comparison of paravalvular leak (PVL) classification by qualitative echocardiography (QE), semi-quantitative echocardiography (SQE), and cardiovascular magnetic resonance (CMR). QE classification included the estimated width of the color Doppler jet in the left ventricular outflow tract: mild (jet width < 25% of left ventricular outflow tract width), moderate (jet width 25 to 65% of left ventricular outflow tract width), and severe (jet width >65% of left ventricular outflow tract width). SQE included the circumferential extent as the sum of the paravalvular leak jet circumference(s) divided by the valve circumference: mild (<10%), moderate (10-30%), and severe (>30%). CMR classification included the aortic regurgitant fraction as calculated by dividing the reverse flow volume by the forward flow volume: mild (≤20%), moderate (21-39%), and severe (≥40%).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4256820&req=5

Fig3: Comparison of paravalvular leak (PVL) classification by qualitative echocardiography (QE), semi-quantitative echocardiography (SQE), and cardiovascular magnetic resonance (CMR). QE classification included the estimated width of the color Doppler jet in the left ventricular outflow tract: mild (jet width < 25% of left ventricular outflow tract width), moderate (jet width 25 to 65% of left ventricular outflow tract width), and severe (jet width >65% of left ventricular outflow tract width). SQE included the circumferential extent as the sum of the paravalvular leak jet circumference(s) divided by the valve circumference: mild (<10%), moderate (10-30%), and severe (>30%). CMR classification included the aortic regurgitant fraction as calculated by dividing the reverse flow volume by the forward flow volume: mild (≤20%), moderate (21-39%), and severe (≥40%).

Mentions: All patients had adequate parasternal short-axis images on echocardiogram for semi-quantitative analysis. Suprasternal notch and subcostal views of the descending aorta were not consistently of diagnostic quality to assess diastolic flow reversal. Parasternal short and long-axis views of the right ventricular outflow tract and pulmonary artery were also not consistently of diagnostic quality to perform quantitative Doppler analysis. PVL classification by QE, SQE, and CMR is shown in Figure 3. Greater than mild PVL was present in 52%, 83% and 52% of patients by QE, SQE, and CMR, respectively. There was a poor correlation between QE and CMR (Spearman r = 0.26, p = 0.24) and a moderate correlation between SQE and CMR (Spearman r = 0.59; p = 0.003). Mean PVL severity was not significantly different by QE and CMR, however, SQE overestimated severity compared to CMR (see Figure 4). PVL was reclassified by CMR in a substantial number of patients compared with QE and SQE (see Table 3).Figure 3


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

Hartlage GR, Babaliaros VC, Thourani VH, Hayek S, Chrysohoou C, Ghasemzadeh N, Stillman AE, Clements SD, Oshinski JN, Lerakis S - J Cardiovasc Magn Reson (2014)

Comparison of paravalvular leak (PVL) classification by qualitative echocardiography (QE), semi-quantitative echocardiography (SQE), and cardiovascular magnetic resonance (CMR). QE classification included the estimated width of the color Doppler jet in the left ventricular outflow tract: mild (jet width < 25% of left ventricular outflow tract width), moderate (jet width 25 to 65% of left ventricular outflow tract width), and severe (jet width >65% of left ventricular outflow tract width). SQE included the circumferential extent as the sum of the paravalvular leak jet circumference(s) divided by the valve circumference: mild (<10%), moderate (10-30%), and severe (>30%). CMR classification included the aortic regurgitant fraction as calculated by dividing the reverse flow volume by the forward flow volume: mild (≤20%), moderate (21-39%), and severe (≥40%).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4256820&req=5

Fig3: Comparison of paravalvular leak (PVL) classification by qualitative echocardiography (QE), semi-quantitative echocardiography (SQE), and cardiovascular magnetic resonance (CMR). QE classification included the estimated width of the color Doppler jet in the left ventricular outflow tract: mild (jet width < 25% of left ventricular outflow tract width), moderate (jet width 25 to 65% of left ventricular outflow tract width), and severe (jet width >65% of left ventricular outflow tract width). SQE included the circumferential extent as the sum of the paravalvular leak jet circumference(s) divided by the valve circumference: mild (<10%), moderate (10-30%), and severe (>30%). CMR classification included the aortic regurgitant fraction as calculated by dividing the reverse flow volume by the forward flow volume: mild (≤20%), moderate (21-39%), and severe (≥40%).
Mentions: All patients had adequate parasternal short-axis images on echocardiogram for semi-quantitative analysis. Suprasternal notch and subcostal views of the descending aorta were not consistently of diagnostic quality to assess diastolic flow reversal. Parasternal short and long-axis views of the right ventricular outflow tract and pulmonary artery were also not consistently of diagnostic quality to perform quantitative Doppler analysis. PVL classification by QE, SQE, and CMR is shown in Figure 3. Greater than mild PVL was present in 52%, 83% and 52% of patients by QE, SQE, and CMR, respectively. There was a poor correlation between QE and CMR (Spearman r = 0.26, p = 0.24) and a moderate correlation between SQE and CMR (Spearman r = 0.59; p = 0.003). Mean PVL severity was not significantly different by QE and CMR, however, SQE overestimated severity compared to CMR (see Figure 4). PVL was reclassified by CMR in a substantial number of patients compared with QE and SQE (see Table 3).Figure 3

Bottom Line: 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).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.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Division of Cardiology, Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia. sleraki@emory.edu.

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.

Show MeSH
Related in: MedlinePlus