Imaging and Quantification of Aortic Regurgitation after TAVI Lutz Buellesfeld MD FSCAI FESC Department of Cardiology Bern University Hospital Switzerland

Lutz Buellesfeld, MD Consulting: Mitralign Medtronic CoreValve Edwards Lifesciences, LLC Abbott Vascular

Transesophageal echocardiography performed within 30 minutes of PHV implantation revealed … a circular stent geometry with a diameter of 21 mm, optimal PHV function with a mean gradient of 9 mm Hg, a valve area of 1.6 cm2 … , and a moderate paravalvular regurgitation through a nonapposed calcified commissure. Circulation. 2002;106:3006-3008.

Mechanisms of Paravalvular Aortic Regurgitation after TAVI Edwards CoreValve Buellesfeld L. JACC Intv. 2012;5(5):578-81

Mechanisms of Paravalvular Aortic Regurgitation after TAVI Mechanisms of Valvular Aortic Regurgitation after TAVI Leaflet-Immobility, -Destruction, Malexpansion

Incidence AR

Impact of AR on Mortality PARTNER A ADVANCE Registry France 2 Registry P<0.0001 Kodali SK et al. N Engl J Med. 2012;366:1686-95 CoreValve ADVANCE Registry: Presented at ACC 2012 FRANCE II Registry: Van Belle et al, TCT 2012

Invasive Hemodynamics Tools to Detect AR Invasive Hemodynamics Aortography Echocardiography

Angiographic Assessment Sellers Criteria Grade 0= No AR Grade 1= Jet to to LVOT disappearing with each systole Grade 2= Contrast filling of entire LV, but with less density compared to aorta Grade 3= Contrast filling of entire LV, with equal density compared to aorta Grade 4= Complete Opacification in diastole on the first beat with greater density compared to aorta Easy to perform Contrast media depending Qualitative assessment Good for the extremes… To document a perfect result or a substantial problem Supravalvular (2-3cm) shot of dye (20ml/s/40ml)

Echocardiographic Assessment Genereux P. JACC 2013: Paravalvular Leak After TAVR: A Comprehensive Review of the Literature

Echocardiographic Assessment Quantitative assessment Adds procedural complexity Gold standard for valve assessment LV Stroke Volume 56 ml RV Stroke Volume 43 ml Regurgitant volume 13 ml SV (LVOT) 56 ml Genereux P. JACC 2013: Paravalvular Leak After TAVR: A Comprehensive Review of the Literature

VARC 2 Criteria to Grade Postprocedural Aortic Regurgitation Mild Moderate Severe Semiquantitative Diastolic flow reversal Absent or brief early diastolic Intermediate Prominent, holodiastolic Circumferential extent <10% 10-29% ≥30% Quantitative Regurgitant volume <30 ml 30-59ml ≥60ml Regurgitant fraction <30% 30-49% ≥50% EROA (cm2) 0.10 cm2 0.10-0.29cm2 ≥0.30cm2 Kappetein J Am Coll Cardiol 2012;60:1438–54

Hemodynamic Assessment Normal Significant AR indicated by: Aortic diastolic pressure drop Low aortic diastolic pressure (DBP <40 mmHg) Loss of aortic dicrotic notch Increase of LVEDP Severe AR Reduced forward LV filling Low output Pulmonary congestion Coronary ischemia

Hemodynamic Assessment AR Index Diastolic Blood Pressure – LV Enddiastolic Pressure x 100 Systolic Blood Pressure Sinning J JACC 2012 Cutoff: 25

1-Year Mortality According to Severity of periprosthetic AR and the AR Index AR index cutoff value 3.5 (1.7–7.5) 0.001 Vasa-Nicotera M. J Am Coll Cardiol Intv 2012;5:858–65

Hemodynamic Assessment Simplified AR Index Diastolic Blood Pressure – LV Enddiastolic Pressure Cutoff: 18mmHg Patsalis P. EuroIntervention 2012 online ahead of print

Comparison of AR Index and Simplified AR Index (25) Simplified AR Index (<18mmHg) Pre 120/75 - 15 Post 120/40 - 30 50 60 8 10 Pre 80/45 - 15 Post 80/35 - 20 38 30 19 15 Pre 150/90 - 15 Post 150/50 - 25 50 75 17 25

Hemodynamic Assessment Integral AR Index Systolic Pressure Time Integral SPTI Diastolic Pressure Time Integral Diastolic Pressure Time Integral DPTI Systolic Pressure Time Integral Cutoff: 0.7 Patsalis P. Am J Physiol Heart Circ Physiol 2013 in-press

Hemodynamic Assessment Integral AR Index 0.7 Patsalis P. Am J Physiol Heart Circ Physiol 2013 in-press

Hemodynamic Assessment Integral AR Index Patsalis P. Am J Physiol Heart Circ Physiol 2013 in-press

Hemodynamic Assessment Normal Easy to perform Quantitative assessment Robust Severe AR

Multimodality Assessment Invasive Hemodynamics Aortography Echocardiography

New Generation Device Edwards SAPIEN 3 New Generation Device Sadra™ Medical Lotus Valve

Diameter Buellesfeld L. JACC Cardiovasc Intv 2013 Diameter Diameter

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