Limitations and difficulties of echocardiographic short-axis assessment of paravalvular leakage after corevalve transcatheter aortic valve implantation
© The Author(s). 2016
Received: 7 June 2016
Accepted: 25 August 2016
Published: 6 September 2016
To make assessment of paravalvular aortic leakage (PVL) after transcatheter aortic valve implantation (TAVI) more uniform the second Valve Academic Research Consortium (VARC) recently updated the echocardiographic criteria for mild, moderate and severe PVL. In the VARC recommendation the assessment of the circumferential extent of PVL in the short-axis view is considered critical. In this paper we will discuss our observational data on the limitations and difficulties of this particular view, that may potentially result in overestimation or underestimation of PVL severity.
KeywordsAortic valve Regurgitation Paravalvular Echocardiography
Data acquisition and analysis/Clinical characteristics
In total 554 transthoracic echocardiograms up to one year after implantation of a CoreValve Revalving System© because of severe AS were analysed. These echocardiograms were acquired according to VARC recommendations in the period 2007–2013 . More specifically, SAX images were scored for the presence of PVL jets according to a clock model . Median age of the patients was 83 years, 46 % were males and body mass index was 26 ± 4. NYHA class 2, 3 and 4 before TAVI was present in 17 %, 63 % and 14 % of patients, respectively (the remaining patients were asymptomatic patients scheduled for cancer surgery). Consent was obtained obtained in all patients for anonymised prospective data collection for research purposes.
False negative parasternal SAX imaging
Localization of PVL
The level of SAX acquisition – “Flying jets”
Other problems in variability in jet numbers, localization and size
PVL jets at different locations may not only be seen in one beat but also in sequential phases of one beat or in different beats, as seen in a rocking prosthesis. This may overestimate the true severity of PVL, although in the case of a rocking prosthesis PVL severity is likely to be severe and not overestimated .
Limitations of our observations
In this paper the focus was on PVL after TAVI. Evaluating the presence and severity of AR should obviously include an assessment of both valvular and paravalvular components, with finally a combined measurement of ‘total’ AR reflecting the total volume load imposed on the LV. At current follow-up duration significant valvular AR is rare; in our institute it is present in a small minority of patients, and constitutes usually only a trace, with more than mild AR seen in the presented series in only a few patients with a not well deployed stent. However, with longer follow-up duration valvular AR will undoubtedly make the assessment of AR severity even more complex.
We reported only on our experience with the CoreValve Revalving System©, because our Edwards SAPIEN™ cohort is too small to provide a meaningful analysis. To what extent the described problems may occur in the Edwards SAPIEN™ prosthesis or other, newer percutaneous aortic valves should be evaluated - and compared to the CoreValve Revalving System© - in future studies. Some of the discussed limitations (acoustic shadowing, imaging level) may be generalizable, whereas others may be more specific for the CoreValve Revalving System©. Of note, comparative papers on PVL severity between different percutaneous valves should be interpreted with caution. Comparing results from centres implanting different prostheses are significantly influenced by operator dependent PVL recordings and measurements with unknown inter-observer and inter-institutional variability. Comparing the performance of two different prostheses in one single centre should take in consideration patient/prosthesis selection bias. In our center the Edwards Sapien prosthesis is used mainly in patients with known conduction abnormalities (pre-existing right bundle branch block) or a sigmoid interventricular septum, and the latter may be predisposing to a higher incidence of PVL .
Clinical implications and future perspectives
Studies that tried to predict the occurrence of PVL almost invariably divided PVL into less or more than mild. The methods to do so varied from abandoned echocardiographic methods to “according to VARC criteria”. Even the last method is acknowledged by the VARC authors to be “not well-validated”  and is prone to important limitations as described in this paper and by Pibarot et al. . The high variability in the incidence of more than mild PVL in CoreValve specific studies (15 % to 34 %) [12, 18] and the variable correlation with angiography and magnetic resonance imaging  may be in part explained by the limitations in PVL assessment. Similarly, studies that related PVL to mortality should therefore also be interpreted with caution .
Use of a quantitative score model that incorporates apart from the SAX circumferential extent of PVL also the radial extent and measurements from standard apical views. These latter views may provide additional information, and in the TAVI population apical views are usually of better quality. Of note, in the apical views the exit of the PVL is seen without interference of the stent, because the latter is positioned deeper in the scan sector. Such a score was recently proposed by Pibarot et al.  - The role of 2D transesophageal echocardiography (usually well tolerated by the elderly) should be explored further because of its superior quality compared to transthoracic echocardiography.
3D colour flow imaging (Fig. 15) has by some been advocated as an accurate method to measure the vena contract of the PVL by imaging the SAX in a true perpendicular manner and imaging at the right level the “neck” of the PVL jet . In our experience, the contribution of transthoracic 3D echocardiography to address the circumferential extent is rather low because of the lesser spatial (and temporal) resolution and the non-existence of a well-described neck in some patients. The role of 3D transesophageal echocardiography should be certainly explored further because of the better spatial resolution.
Newly developed I-Rotate transducers do allow a full electronic rotation of 360° (adjustable by 5° steps) around the CoreValve prosthesis with excellent spatial and temporal resolution . Similarly as studying the PVL extent of a mitral prosthesis with transesophageal echocardiography it may now be possible to study the PVL extent of a TAVI prosthesis by use of I-rotate colour Doppler in apical views, so avoiding interference with imaging of PVL jets by crushed native material or the stent (Fig. 16).
The transthoracic echocardiographic SAX analysis of PVL is prone to important limitations and difficulties that may result in overestimation or underestimation of PVL severity. Future guidelines should incorporate these limitations and provide clear advices how to deal with them, in particular in case of eccentric jets and variability in jet size.
Transcatheter aortic valve implantation
Valve Academic Research Consortium
There are no sources of funding.
Availability of data and materials
Available data is presented in the main paper.
ML and OS conceived the study idea, performed data analysis and interpretation, and drafted the manuscript. All other authors reviewed and edited the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
No consent for publication to disclose.
Ethics approval and consent to participate
This study was approved by the local institutional board and all patients provided informed consent as mentioned above.
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