How Should We Manage PAR After TAVI?

Stefan Toggweiler, MD

Evidence indicates that postprocedural moderate or severe paravalvular regurgitation (PAR) reduces life expectancy in such a way that it may even nullify the beneficial effect of TAVI.
Due to improved implantation techniques, knowledge, and materials, the rates of moderate or severe PAR have dropped to less than 5%-10% in most recently published trials and registries, but mild PAR still occurs quite frequently. Many interventional cardiologists now aim for the “perfect” result, and even mild PAR seems to justify postdilatation of a transcatheter valve. However, we should keep in mind that postdilatation carries the risks of annular injury, valve displacement, and embolization of calcific debris.
In our study published in the month’s JIC, we investigated the natural course of PAR after implantation of the self-expandable CoreValve. Patients underwent transesophageal echocardiography after 30 days and 1 year. In most patients, PAR improved. Very small jets disappeared, and larger jets became smaller. Overall, we observed an impressive reduction by about 45% between 30 days and 1 year post TAVI. During the first minutes, hours, or days, PAR may lessen due to improved annular apposition and expansion of the frame. However, long-term improvement is more likely due to endothelialization of the frame (see illustration below).


Illustration: The natural course of paravalvular regurgitation after implantation of a self-expandable valve.

Accordingly, postdilation should only be performed in patients with hemodynamically relevant (more than mild) PAR, as mild PAR may spontaneously improve or disappear during the first year of follow-up. If relevant PAR is present after implantation of a self-expandable valve without obvious underexpansion or malpositioning, it is advisable to wait 5-10 minutes, observe hemodynamics, and perform another supravalvular injection of contrast dye. PAR will spontaneously improve in many patients.

Stefan Toggweiler, MD is the head of the interventional valve programme at the Heart Center Lucerne in Lucerne, Switzerland.

Read the entire article here:

Natural Course of Paravalvular Regurgitation After Implantation of the Self-Expanding CoreValve: Insights From Serial TEE Measurements, by Stefan Toggweiler, MD;  Bram van Schie, MD;  Michel Zuber, MD;  Zaid Sabti, MD;  Tardu Özkartal, MD;  Thomas F. Lüscher, MD;  Paul Erne, MD

J INVASIVE CARDIOL 2015;27(9):435-440

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