Paravalvular leak after transcatheter aortic valve implantation: is it anatomically predictable or procedurally determined? MDCT study

Abstract

Aim: To investigate the determinants of paravalvular leak (PVL) occurring after transcatheter aortic valve implantation (TAVI).

Materials and methods: One hundred and eight patients with severe symptomatic aortic stenosis (mean age 75.5±11.8 years, 72.2% male) underwent contrast-enhanced electrocardiogram (ECG)-gated multidetector computed tomography (MDCT) then successful TAVI. The following parameters were determined in the late systolic phase: annular and left ventricular outflow tract (LVOT) diameters, annular perimeter, ellipticity index, annular area, indexed annular area, LVOT perimeter, annulus/LVOT perimeter difference ratio, the LVOT to ascending aorta angle (< LVOT-AO). In the diastolic phase, the extent of calcification of the aortic valve (AVC) was assessed visually and graded semi-quantitatively as grade I, II, and III at the annulus, LVOT, and aortic cusps levels. Pre-discharge transthoracic echocardiography (TTE) was performed, and the PVL was graded as grade I, II, and III. The area-dependent device-annulus sizing ratio was calculated.

Results: Absence of PVL was observed in 44.44% of the patients, 30.56% had grade I PVL, 25% of the patients had grade II or above, and any PVL was observed in 55.56%. There was no statistically significant association between the degree of PVL and the extent or the distribution of AVC, aortic annulus diameters, ellipticity index, annulus/LVOT perimeter difference ratio or < LVOT-AO. The frequency of PVL was not significantly different with the use of balloon-expandable or self-expandable valves. A larger transcatheter heart valve (THV)/annulus sizing ratio was associated with a lower incidence and degree of PVL (p<0.001); there was no detectable PVL with a mean sizing ratio of 14.89±7.29, and grade I PVL occurred with a mean sizing ratio 12.43±0.84, while PVL of grade II or above occurred using the mean sizing ratio -0.42±5.57.

Conclusion: The procedure-related THV/annulus sizing ratio was an important determinant of the degree of PVL after TAVI, whereas the MDCT-derived anatomical measurements of the aortic root and AVC were not predictors of PVL.