Mild paravalvular regurgitation is not an independent predictor of mortality following TAVI
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1 Mild paravalvular regurgitation is not an independent predictor of mortality following TAVI Philippe Pibarot, DVM, PhD, FACC, FAHA, FASE Canada Research Chair in Valvular Heart Diseases INSTITUT UNIVERSITAIRE DE CARDIOLOGIE ET DE PNEUMOLOGIE DE QUÉBEC Université LAVAL
2 Disclosure Statement Grant funding: - Canadian Institutes of Health Research - Heart and Stroke Foundation of Canada Industry: - Edwards Life Science: Research grant Echo Core Lab TAVI - V-Wave Ltd. Research grant Echo Core Lab Heart failure
3 PVR TAVI
4 Impact of Paravalvular Regurgitation on 2-Year Outcomes: PARTNER-I A Trial Paravalvular Regurgitation Total (Paravalvular+Central) Regurgitation Kodali et al.; NEJM 2012
5 1- Is it really mild PVR? 3 Main Questions: 2- Is Mild PVR an actor or a marker? 3- Does mild PVR have a significant and independent impact on survival?
6 Question #1: Is it really mild PVR?
7 Quantification of Transcatheter Valve Regurgitation Zoghbi et al. J Am Soc Echocardiogr, 22: , 2009 Pibarot & Dumesnil, Heart, 98:69-78, 2012
8
9 Grading Severity of Paravalvular Regurgitation Bloomfield; JACC Img; 5:441 55, 2012
10 Multi-window Imaging is Key! SAX LAX 5Ch 3Ch Gonçalves et al. J Am Soc Echocardiogr 2012;25:47-55
11 Multi-window Imaging is Key! SAX View LAX View Apical 5-Ch View Apical 3-Ch View
12 Overestimation of Circumferential Extent with Eccentric Jets LAX View SAX View
13 Overestimation of Circumferential Extent with Eccentric Jets SAX View SAX View
14 Circumferencial Extent of PVR versus CMR to Assess AR Following TAVR Ribeiro HB, et al. Heart, 2014
15 Ribeiro HB, et al. Heart, 2014
16 Multi-View/Multi Parametric TTE versus CMR to Assess AR Following TAVR Ribeiro HB, et al. Heart, 2014
17 Echo versus CMR to Assess AR Following TAVR Orwat et al. Heart 2014
18 Question #2: Is Mild PVR Marker or an Actor? Gilbreath C. Opt. Eng. 51(2) March 2012
19 Predictors of Paravalvular Regurgitation following TAVI Male gender NYHA Class IV Atrial fibrillation AR at baseline MR at baseline Severity and distribution of valve calcification Larger aortic annulus Smaller cover index Inadequate valve positioning Self expending valve Sinning et al. JACC, 2012 Haensig M, EJCTS, 2012 Ewe et al. Am J Cardiol 2011 Ubehaum et al. JACC, 2012 Sinning et al. JACC 2013
20 Are patients with mild PVR the same as those with none/trace PVR?
21 Baseline Characteristics of TAVR Patients with Paravalvular Regurgitation in the PARTNER Trial Kodali et al. Eur Heart J 2014
22 Impact of PVR on Mortality in the PARTNER Trial Kodali et al. Eur Heart J 2014
23 Question #3: Does Mild PVR have a signifiant impact on survival? Kodali et al.; NEJM 2012
24 Survival Under Conservative Management After Diagnosis of Native AR Detaint D et al. J Am Coll Cardiol Img 2008;1:1 11
25 Mild PVR post-savr
26 Mild PVR post-savr
27 Impact of Paravalvular Regurgitation on 2-Year Outcomes: PARTNER-I A Trial Paravalvular Regurgitation Total (Paravalvular+Central) Regurgitation Kodali et al.; NEJM 2012
28 Impact of Moderate-Severe AR on Mortality after TAVI: A Meta-analysis Athapan et al. JACC 2013
29 Impact of Mild AR on Mortality after TAVI: A Meta-analysis High Heterogeneity (I 2 : 75.28) Sensitivity Analysis: negative results after removing 1 single study Athapan et al. JACC 2013
30 Impact of AR Post-TAVI / France-2 Registry n= 2769 Van Belle et al. Circulation 2014
31 Impact AR Post-TAVI / UK Registry Dworakowski R, et al. Heart 2014
32 Impact of AR on Mortality: Medtronic CoreValve ADVANCE Registry 1,015 patients enrolled from March 2010 to July 2011 in 44 centers 12 countries Linke A et al. TCT 2012
33 Impact of AR on Mortality CoreValve Pivotal Trial Popma et al. JACC 2014
34 Impact of AR on Mortality after TAVI: Multicenter Study (1735 Patients) Jerez-Valero et al. J Am Coll Cardiol Intv 2014;7:
35 Effect of Acuteness of AR on Mortality After TAVI: Multicenter Study (1735 Patients) Jerez-Valero et al. J Am Coll Cardiol Intv 2014;7:
36 Effect of Acuteness of AR on Mortality After TAVI: France 2 Registry Van Belle et al. Circulation 2014
37 An acute mild PVR could be harmful in patients with small non-compliant LV?
38 Impact of Balloon Post-dilation on PVR And Outcomes Pre-BPD Post-BPD
39 Impact of Balloon Post-dilation on PVR And Outcomes PD: 2.5-fold increase in the risk of early cerebrovascular events Nombela-Franco et al. JACC CV Intervention 2012 Nombela-Franco et al. Circulation 2012
40 Conclusions Moderate/severe PVR occurs in 2-25% of patients and is an independent predictor of mortality Mild PVR is frequent (7-70%) following TAVR The association between mild PVR and increased mortality is in large part related to worse baseline risk profile Mild PVR may have an impact on mortality if: It is underestimated It occurs in a patient with no pre-existing AR and/or restrictive LV physiology
41 Clinical Implications Current data do not justify additional measures (balloon post-dilation, valve-in-valve, leak closure, SAVR) in patients with mild PVR post-tavi Need to develop Doppler-echo methods to improve quantitation of PVR Need to improve transcatheter heart valves and procedures to minimize/eliminate PVR Optimize Sizing with 3D imaging of annulus Balloon post-dilation, V-inV New valve models with better sealing
42
Paravalvular Regurgitation is a Risk Factor Following TAVI
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