Cardiovascular magnetic resonance and transesophageal echocardiography in patients with prosthetic valve paravalvular leaks: towards an accurate quantification and stratification

Abstract

Background Objective assessment of prosthetic paravalvular leak (PVL) is complex and challenging even in transesophageal echocardiography (TEE). Our aim was to assess the value of cardiovascular magnetic resonance (CMR) in quantifying PVL in aortic (AVR) or mitral valve (MVR) replacement. Methods Thirty-one patients (62 ± 15.1 years, 63% males) with a preliminary diagnosis of significant PVL (AVR, n-23; MVR, n = 8) were recruited. The TEE PVL grading was based on the semi-quantitative (SQ) TEE according to the VARC II PVL classification (%PVL: mild < 10%; moderate 10%–30%; severe > 30%). Non-contrast CMR studies were acquired at 1.5 T with a quantitative approach (phase-contrast velocity encoded imaging). The CMR PVL severity was classified according to regurgitant fraction (RF: (1) mild ≤ 20%, (2) moderate 21%–39%, or (3) severe ≥ 40%). Results All patients revealed symptoms of heart failure (71%: New York Heart Association [NYHA] II; 91%: N-terminal pro-B-type natriuretic peptide [NT-proBNP] > 150 pg/ml) and typical cardiovascular disease risk factors. The SQ-TEE results revealed several categories: (1) mild (n = 5; 16%), (2) moderate (n = 21; 67%), and (3) severe (n = 5; 16%) PVL. However, CMR PVL RF reclassified the severity of PVL: (1) mild to moderate (in 80%), (2) moderate to severe (in 47%), and (3) severe to moderate (in 40%). The receiver operating characteristic analysis showed that SQ-TEE and CMR PVL-vol and -RF predicted the upper tertile of NT-proBNP (> 2000 pg/ml) with the best sensitivity for CMR parameters. Conclusion The SQ-TEE showed moderate agreement with CMR and underestimated a considerable number of AVR or MVR-PVL.

Case report: Paravalvular regurgitation post transcatheter aortic valve replacement: When in doubt choose cardiac magnetic resonance

“…This approach has applications beyond TAVR. Compared with transesophageal echocardiography (TEE), CMR appears to have higher sensitivity to detect significant periprosthetic regurgitation after both surgical AVR or MVR ( 7 , 8 ). Semiquantitative TEE underestimates a considerable number of AVR or MVR PVL ( 7 ).…”

“…Compared with transesophageal echocardiography (TEE), CMR appears to have higher sensitivity to detect significant periprosthetic regurgitation after both surgical AVR or MVR ( 7 , 8 ). Semiquantitative TEE underestimates a considerable number of AVR or MVR PVL ( 7 ). 4D flow CMR has also been used in a patient to detect a PVL after pulmonary valve replacement, and it was helpful to accurately quantify an effective regurgitant volume for decision making ( 9 ).…”

Echocardiography and Cardiac Magnetic Resonance in the Assessment of Left-Ventricle Remodeling: Differences Implying Clinical Decision

“…This prospective single-center study was performed in the Upper-Silesian Medical Center of the Medical University of Silesia in Katowice. Some of the study patients (within Groups 1 and 3) that were scheduled for CMR were included in our previous papers evaluating distinct aspects of cardiac imaging, which are not related to this study (quantification of paracardial fat depots or quantification of native and paravalvular aortic regurgitations) [ 11 , 12 , 13 ]. This paper presents results that have not been used or published before.…”

Incidence of valvular regurgitation and leaflet perforation by using automated titanium fasteners (CORKNOT®) in heart valve repair or replacement: less usual than reported

“…Objective assessment of PVL may be challenging [15] and may require cardiovascular magnetic resonance (CMR) to quantify. However, Transesophageal echo is still the gold standard method for immediate post procedure assessment of heart valve repair or replacement [16]. Additionally, Patients with PVL may remain asymptomatic for long period and can be associated with heart failure, hemolysis and/or endocarditis [17].…”