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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.

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Primary composite outcome Kaplan-Meier survival analysis for patients with greater than mild paravalvular leak (PVL) by imaging method. QE = qualitative echocardiography, SQE = semi-quantitative echocardiography, CMR = cardiovascular magnetic resonance. CE = circumferential extent. Primary composite outcome = repeat invasive therapy, heart failure hospitalization, and all-cause death.
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Fig6: Primary composite outcome Kaplan-Meier survival analysis for patients with greater than mild paravalvular leak (PVL) by imaging method. QE = qualitative echocardiography, SQE = semi-quantitative echocardiography, CMR = cardiovascular magnetic resonance. CE = circumferential extent. Primary composite outcome = repeat invasive therapy, heart failure hospitalization, and all-cause death.

Mentions: At one year (mean 11.5 ± 1.4 months), 48% of the patients met the primary composite outcome of all-cause death, heart failure hospitalization, and intractable heart failure symptoms necessitating repeat invasive therapy (see Table 4). The average time to first event was 51 days (9 days for repeat invasive therapy, 97 days for heart failure admission, and 118 days for all-cause death). Patients who experienced the primary outcome had significantly higher serum creatinine levels at the time of CMR (1.9 ± 0.80 mg/dl versus 1.17 ± 0.32 mg/dl, p = 0.008) and higher EF by CMR (53 ± 10% versus 44 ± 12%, p = 0.048). The primary outcome occurred in 9%, 71%, and 100% of patients with mild, moderate, and severe PVL by CMR, respectively. Patients with greater than mild PVL by CMR were more likely to experience the primary outcome compared to those with mild or less PVL (p = 0.001), while patients with greater than mild PVL by QE or SQE were not (p = 1.0 and p = 0.093, respectively). Otherwise, there were no significant baseline differences in patients with and without a primary outcome event. Severity of PVL by QE, SQE, and CMR in those with and without a primary outcome event is shown in Figure 5. Kaplan-Meier survival analysis stratified by greater than mild PVL stratified by QE, SQE, and CMR is shown in Figure 6.Table 4


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)

Primary composite outcome Kaplan-Meier survival analysis for patients with greater than mild paravalvular leak (PVL) by imaging method. QE = qualitative echocardiography, SQE = semi-quantitative echocardiography, CMR = cardiovascular magnetic resonance. CE = circumferential extent. Primary composite outcome = repeat invasive therapy, heart failure hospitalization, and all-cause death.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig6: Primary composite outcome Kaplan-Meier survival analysis for patients with greater than mild paravalvular leak (PVL) by imaging method. QE = qualitative echocardiography, SQE = semi-quantitative echocardiography, CMR = cardiovascular magnetic resonance. CE = circumferential extent. Primary composite outcome = repeat invasive therapy, heart failure hospitalization, and all-cause death.
Mentions: At one year (mean 11.5 ± 1.4 months), 48% of the patients met the primary composite outcome of all-cause death, heart failure hospitalization, and intractable heart failure symptoms necessitating repeat invasive therapy (see Table 4). The average time to first event was 51 days (9 days for repeat invasive therapy, 97 days for heart failure admission, and 118 days for all-cause death). Patients who experienced the primary outcome had significantly higher serum creatinine levels at the time of CMR (1.9 ± 0.80 mg/dl versus 1.17 ± 0.32 mg/dl, p = 0.008) and higher EF by CMR (53 ± 10% versus 44 ± 12%, p = 0.048). The primary outcome occurred in 9%, 71%, and 100% of patients with mild, moderate, and severe PVL by CMR, respectively. Patients with greater than mild PVL by CMR were more likely to experience the primary outcome compared to those with mild or less PVL (p = 0.001), while patients with greater than mild PVL by QE or SQE were not (p = 1.0 and p = 0.093, respectively). Otherwise, there were no significant baseline differences in patients with and without a primary outcome event. Severity of PVL by QE, SQE, and CMR in those with and without a primary outcome event is shown in Figure 5. Kaplan-Meier survival analysis stratified by greater than mild PVL stratified by QE, SQE, and CMR is shown in Figure 6.Table 4

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