Author + information
- Received October 15, 2014
- Accepted November 22, 2014
- Published online April 27, 2015.
- Taisei Kobayashi, MD∗ (, )
- Jay Giri, MD, MPH,
- Prashanth Vallabhajosyula, MD,
- Howard C. Herrmann, MD and
- Dinesh H. Jagasia, MD
- ↵∗Reprint requests and correspondence:
Dr. Taisei Kobayashi, Department of Cardiovascular Medicine, University of Pennsylvania, 3400 Spruce Street, Gates 9, Philadelphia, Pennsylvania 19104.
An 88-year-old woman with a history of severe aortic stenosis presented for a transaortic valve replacement (TAVR). A pre-TAVR computed tomography angiogram showed an aortic annular area of 385 mm2 and an average diameter of 22.1 mm (Figure 1A). The patient underwent an uncomplicated transfemoral #23 SAPIEN 3 valve (Edwards Lifesciences, Irvine, California) implantation.
The presence of a paravalvular leak (PVL) after TAVR may be associated with increased mortality (1). However, the assessment of paravalvular aortic regurgitation (AR) after TAVR is challenging. One of the widely used criteria for grading a PVL suggested by the Valve Academic Research Consortium (VARC-2) uses the circumferential extent of the prosthetic valve PVL (i.e., <10% indicates mild PVL, 10% to 29% indicates moderate PVL, and ≥30% indicates severe PVL) (2). The balloon-expandable Edwards SAPIEN 3 transcatheter heart valve has a novel design with an outer skirt to reduce PVL after TAVR.
In our patient, aortography immediately after TAVR revealed mild PVL (Figure 1B, Online Video 1). Transthoracic echocardiography performed the next day suggested severe PVL based on a >30% circumferential extent of PVL in the parasternal short-axis (PSAX) view obtained just above the level of the skirt of the SAPIEN 3 valve (Figure 1C, Online Video 2). However, the apical 3-chamber view and PSAX view obtained just below the level of the skirt showed only mild PVL (Figure 1D, Online Video 3 and Figure 1E, Online Video 4). The prominent circumferential diastolic color flow signal noted in the aortic root (at and above the skirt of the SAPIEN 3 valve) may lead to overestimation of PVL. The echocardiographic assessment of PVL must be done from multiple views. The evaluation of the circumferential extent of PVL must be carefully performed below the aortic annulus and the skirt of the SAPIEN 3 valve to avoid overestimation of severity of PVL.
For supplemental videos and their legends, please see the online version of this article.
Dr. Hermann has received institutional research grants from Abbott Vascular, Edwards Lifesciences, St. Jude Medical, Core, Siemens, and Boston Scientific; is a consultant for Siemens and Edwards Lifesciences; and holds equity in Microinterventional Devices. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 15, 2014.
- Accepted November 22, 2014.
- American College of Cardiology Foundation