Assessment of the Severity of Paravalvular Regurgitation and its Role on Survival After Transcatheter Aortic Valve Replacement

<b>Background:</b> To evaluate the impact of various measurements of paravalvular regurgitation (PVR) on survival after transcatheter aortic valve replacement (TAVR). PVR can be difficult to grade and both its incidence and impact on survival may be decreasing as TAVR evolves. <b>Methods:</b> This retrospective study included 911 patients undergoing TAVR in two institutions. PVR was graded according to the 3-grade scheme proposed by the guidelines (PVR grade), and subsequently grade 2 and 3, and grade 0 and 1 were lumped together. PVR was also graded as a composite score (PVR score), based on 6 commonly used metrics. PVR grade, PVR score and its six individual components were tested against the risk of both 1-year and longer term mortality after TAVR. <b>Results:</b> Patients with moderate/severe PVR had a higher Society of Thoracic Sugeons (STS) score, higher levels of serum creatinine and larger left atria compared to patients with none/mild PVR. Moderate/severe PVR was more frequent with self-expandable and larger valves. After adjusting for American College of Cardiology (ACC) TAVR risk score, neither PVR grade, PVR score nor its six components were associated with an increased risk of mortality at 1-year (severe PVR adjusted HR: 0.75, 95% Confidence Interval [CI]: 0.19, 3.01, <i>p</i> = 0.50). However, intervention for clinically severe PVR increased the risk of mortality by more than 7-fold (adjusted hazard ratio [HR]: 7.6, 95% CI: 2.4, 23.5, <i>p</i> <b>Conclusions:</b> In the contemporary era, moderate-severe PVR is uncommon. However, re-intervention for PVR portends a poor prognosis. This highlights the crucial importance of clinical judgment over imaging alone.

<b>背景：</b>本研究旨在评估经导管主动脉瓣置换术（transcatheter aortic valve replacement, TAVR）后，不同评估方式下的瓣周反流（paravalvular regurgitation, PVR）对患者生存结局的影响。瓣周反流分级难度较高，且随着经导管主动脉瓣置换术技术的迭代，其发生率及对生存的影响均呈下降趋势。<b>方法：</b>本回顾性研究纳入了两家医疗中心共911名接受经导管主动脉瓣置换术（TAVR）的患者。研究人员依据指南提出的3级分级方案对瓣周反流（PVR）进行分级（即PVR分级），随后将2级与3级、0级与1级分别合并。同时，基于6项常用评估指标，将瓣周反流评为复合评分（PVR评分）。随后分别分析PVR分级、PVR评分及其6项独立组分与经导管主动脉瓣置换术后1年及长期死亡风险的相关性。<b>结果：</b>与无/轻度瓣周反流患者相比，中/重度瓣周反流患者的胸外科医师学会（Society of Thoracic Surgeons, STS）评分更高、血清肌酐水平更高且左心房内径更大。自膨胀式瓣膜及更大尺寸瓣膜植入后，中/重度瓣周反流的发生率更高。在校正美国心脏病学会（American College of Cardiology, ACC）经导管主动脉瓣置换术风险评分后，无论是PVR分级、PVR评分还是其6项独立组分，均与术后1年死亡风险升高无显著相关性（重度PVR校正后风险比：0.75，95%置信区间[CI]：0.19~3.01，<i>p</i>=0.50）。然而，针对临床重度瓣周反流的干预措施可使死亡风险升高7倍以上（校正后风险比[HR]：7.6，95%置信区间[CI]：2.4~23.5，<i>p</i>）。<b>结论：</b>在当代临床实践中，中重度瓣周反流已较为少见。然而，针对瓣周反流的再次干预往往提示预后不良。这一结果凸显了临床判断相较于单纯影像学评估的关键重要性。