Assessment of paravalvular leakage after transcatheter aortic valve implantation: add clinical signs to echocardiographic data.

Summary

A 62-year-old male with pulmonary fibrosis and aortic valve stenosis underwent TAVI (Corevalve Evolut XL 34 mm) in the build-up for lung transplantation (LuTx). Following post-dilation for a large annular perimeter, moderate paravalvular aortic regurgitation (AR) was observed (Video 1). After 6 weeks, he was admitted to the ICU with respiratory failure (Fig. 1A). TTE demonstrated residual mild AR (based on a small excentric paravalvular AR jet, <10% circumferential extent, pressure half-time was not reliably measured) and together with borderline elevated NT-pro-BNP, the consultant cardiologist authorized LuTx listing.

Figure 1

(A) Chest X-ray, reticular shadowing of lung parenchyma and pleural fluid; (B) Radial arterial pressure waveform, rapid upstroke, diminished dicrotic notch and wide pulse pressure (200/50 mmHg); (C) Doppler ultrasound of femoral artery, holo-diastolic flow reversal; (D) TTE, parasternal short-axis view, paravalvular AR; (E) TTE, suprasternal long-axis view of descending aorta, holo-diastolic flow reversal; (F) PA specimen of the TAVI seen from the ascending aorta, where a probe indicates the leak.

Aortography at the time of the procedure, showing grade 3 aortic regurgitatation. View Video 1 at http://movie-usa.glencoesoftware.com/video/10.1530/ERP-17-0041/video-1.

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However, an abnormal radial arterial pressure waveform was noticed (Fig. 1B). Femoral artery Doppler ultrasound demonstrated holo-diastolic backflow (Duroziez’s sign, Fig. 1C), which may indicate severe AR. Repeat biplane TTE confirmed 30% circumferential paravalvular AR (Fig. 1D, Videos 2 and 3) and descending aorta end-diastolic flow reversal >20 cm/s (Fig. 1E), consistent with the diagnosis.

Parasternal long-axis view showing paravalvular aortic regurgitation through colour-Doppler at the TAVI stent inflow level. View Video 2 at http://movie-usa.glencoesoftware.com/video/10.1530/ERP-17-0041/video-2.

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Parasternal biplane view, colour-Doppler, showing paravalvular aortic regurgitation. View Video 3 at http://movie-usa.glencoesoftware.com/video/10.1530/ERP-17-0041/video-3.

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The patient deteriorated rapidly. Given the shortage of donor organs, the option of LuTx after ECMO-assisted paravalvular leak closure (with unpredictable result) was deemed inappropriate. He died and autopsy was done (Fig. 1F).

Assessment of the severity of AR after TAVI is challenging. Determination of the circumferential extent of paravalvular AR assessed by TTE is regarded ‘critical’, but may be difficult (1, 2, 3, 4). Although transoesophageal echocardiography may be the default technique in case of uncertainty, this was impossible since this would have required mechanical ventilation, which can be very challenging in end-stage pulmonary fibrosis. In conclusion, clinical signs together with all possible echocardiography views are paramount for the diagnosis.

Declaration of interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this article.

Funding

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Patient consent

This patient deceased, but permission for publication was obtained from next-of-kin.