Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC TBYy4HycDqhCHywqxDqVbsB S0066-782X2018001400203 10.5935/abc.20180158 Short Editorial New Method Improves the Assessment of Aortic Regurgitation Grade during TAVR by Aortography Ribeiro Henrique B. Universidade de São Paulo Instituto do Coração de São Paulo São Paulo SP Brazil Instituto do Coração de São Paulo - Universidade de São Paulo, São Paulo, SP - Brazil Mailing Address: Henrique B. Ribeiro Instituto do Coração (InCor) de São Paulo, Universidade de São Paulo – Av. Dr. Eneas de Carvalho Aguiar, 55. Postal Code 05403-000, São Paulo, SP – Brazil E-mail: hbribeiro@gmail.com 08 2018 111 2 203 204 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Keywords Transcatheter Aortic Valve Replacement/methods Aortic Valve Insufficiency/mortality Aortic Valve Insufficiency/diagnostic imaging Echocardiography, Three-Dimensional/methods Aortography/methods

Transcatheter aortic valve replacement (TAVR) is a rapidly expanding alternative to surgical aortic valve replacement for patients deemed inoperable or at high or intermediate operative risk. Yet, residual aortic regurgitation (AR) secondary to paravalvular leaks (PVL) remains a procedural limitation.1 Although residual AR after TAVR is frequent, affecting up to approximately 70% of the treated patients,2-4 it is moderate to severe in approximately 12% of these4 and steadily below 5% with current-generation devices, which come with specific sealing features.1 Noteworthy, moderate/severe AR has a detrimental clinical impact after TAVR, with a 3-fold increase in 30-day mortality and a 2.3-fold increase in 1-year mortality.4 Thus, its accurate assessment and quantification with a multimodality approach is key for appropriate utilization of additional procedures to reduce PVL, such as balloon post-dilatation (BPD), valve-in-valve, or leak closure.1,5

While Doppler echocardiography has been the most common method to assess AR following TAVR, its accurate quantification is challenging since AR jets are often multiple and eccentric.3,5-7 Therefore, other methods for proper AR assessment have been evaluated in recent years, such as 3D echocardiography, hemodynamic AR index, aortography and even cardiovascular magnetic resonance, each one with its specific advantages and disadvantages.1,5,7

In the current issue of the journal, Miyazaki et al.8 investigate a quantitative angiographic assessment of AR by videodensitometry (VD-AR) before and after BPD was performed. VD-AR was shown to decrease significantly from 24.0 [18.0-30.5] % to 12.0 [5.5-19.0] % (p < 0.001) after BPD, with some degree of AR grade improvement for up to 70% of patients treated. Of note, significant AR (VD-AR > 17%) was observed in 47 patients (77%) before and in 19 patients (31%) after BPD; moreover, in up to a quarter of these, pre-BPD VD-AR was below 17%, indicating that this additional maneuver could have been avoided. The study has its inherent limitations, e.g., the cohort was relatively small, with retrospective patient selection and imaging acquisition, and the decision whether or not to perform BPD was left to the discretion of the operators. Accordingly, the study only comprises cases where BPD was deemed necessary, and only aortograms with good quality imaging were selected.

Notably, the technique used to quantify VD-AR is a novel method that can accurately determine the regurgitation fraction in aortograms performed during TAVR; it uses dedicated software and showed excellent reproducibility and accuracy.9,10 This technique provides an accurate assessment of the severity of PVL, and a VD-AR index greater than 17% correlated with increased mortality and with impaired cardiac reverse remodeling after TAVR.11,12 And while VD-AR measurements are performed offline only, real-time online assessment is underway so as to enable this method to help guiding TAVR in the near future. After all, BPD is currently performed in about 10% to 20% of patients following TAVR, and it reduces the severity of PVL by at least one grade in more than two thirds of patients.13,14 Nevertheless, BPD may be associated with an increased risk of cerebrovascular events and annular trauma, therefore judicious utilization of this procedure is recommended.13,14

In conclusion, since PVL has a negative impact on clinical outcomes after TAVR, its proper assessment through a multimodality, multiparametric, integrative approach is fundamental. Priority should be given to PVL prevention through accurate sizing of aortic annulus by 3D imaging techniques, THV devices with improved sealing features, and optimal THV sizing and positioning. Still, if PVL does occur after TAVR, the interventional cardiologist can consider corrective procedures such as BPD, valve-in-valve, or leak closure. The novel VD-AR after TAVR also allows quantitatively assessing post-TAVR regurgitation and may assist decision making on whether or not to perform BPD, as well as determining its efficacy. Future prospective studies are warranted to further confirm the present results.

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Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis: A Longitudinal Study of Echocardiography Parameters in cohort A of the PARTNER trial (placement of aortic transcatheter valves). J Am Coll Cardiol. 2013;61(25):2514-21. Hahn RT Pibarot P Stewart WJ Weissman NJ Gopalakrishnan D Keane MG Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis A Longitudinal Study of Echocardiography Parameters in cohort A of the PARTNER trial (placement of aortic transcatheter valves) J Am Coll Cardiol 2013 61 25 2514 2521 4 Athappan G, Patvardhan E, Tuzcu EM, Svensson LG, Lemos PA, Fraccaro C, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol. 2013;61(15):1585-95. Athappan G Patvardhan E Tuzcu EM Svensson LG Lemos PA Fraccaro C Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement meta-analysis and systematic review of literature J Am Coll Cardiol 2013 61 15 1585 1595 5 Ribeiro HB, Orwat S, Hayek SS, Larose E, Babaliaros V, Dahou A, et al. Cardiovascular magnetic resonance to evaluate aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol. 2016;68(6):577-85. Ribeiro HB Orwat S Hayek SS Larose E Babaliaros V Dahou A Cardiovascular magnetic resonance to evaluate aortic regurgitation after transcatheter aortic valve replacement J Am Coll Cardiol 2016 68 6 577 585 6 Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2009;22(9):975-1014. Zoghbi WA Chambers JB Dumesnil JG Foster E Gottdiener JS Grayburn PA Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography J Am Soc Echocardiogr 2009 22 9 975 1014 7 Ribeiro HB, Le Ven F, Larose E, Dahou A, Nombela-Franco L, Urena M, et al. Cardiac magnetic resonance versus transthoracic echocardiography for the assessment and quantification of aortic regurgitation in patients undergoing transcatheter aortic valve implantation. Heart. 2014;100(24):1924-32. Ribeiro HB Le Ven F Larose E Dahou A Nombela-Franco L Urena M Cardiac magnetic resonance versus transthoracic echocardiography for the assessment and quantification of aortic regurgitation in patients undergoing transcatheter aortic valve implantation Heart 2014 100 24 1924 1932 8 Miyazaki Y, Modolo R, Abdelghani M, Tateishi H, Cavalcante R, Collet C, et al. Papel da avaliação aortográfica quantitativa da regurgitação aórtica por videodensitometria na orientação do implante da valva aórtica transcateter. Arq Bras Cardiol. 2018; 111(2):193-202. Miyazaki Y Modolo R Abdelghani M Tateishi H Cavalcante R Collet C Papel da avaliação aortográfica quantitativa da regurgitação aórtica por videodensitometria na orientação do implante da valva aórtica transcateter Arq Bras Cardiol 2018 111 2 193 202 9 Abdel-Wahab M, Abdelghani M, Miyazaki Y, Holy EW, Merten C, Zachow D, et al. A novel angiographic quantification of aortic regurgitation after TAVR provides an accurate estimation of regurgitation fraction derived from cardiac magnetic resonance imaging. JACC Cardiovasc Interv. 2018;11(3):287-97. Abdel-Wahab M Abdelghani M Miyazaki Y Holy EW Merten C Zachow D A novel angiographic quantification of aortic regurgitation after TAVR provides an accurate estimation of regurgitation fraction derived from cardiac magnetic resonance imaging JACC Cardiovasc Interv 2018 11 3 287 297 10 Abdelghani M, Miyazaki Y, de Boer ES, Aben JP, van Sloun M, Suchecki T, et al. Videodensitometric quantification of paravalvular regurgitation of a transcatheter aortic valve: in vitro validation. EuroIntervention. 2018;13(13):1527-35. Abdelghani M Miyazaki Y de Boer ES Aben JP van Sloun M Suchecki T Videodensitometric quantification of paravalvular regurgitation of a transcatheter aortic valve in vitro validation EuroIntervention 2018 13 13 1527 1535 11 Tateishi H, Campos CM, Abdelghani M, Leite RS, Mangione JA, Bary L, et al. Video densitometric assessment of aortic regurgitation after transcatheter aortic valve implantation: results from the Brazilian TAVI registry. EuroIntervention. 2016;11(12):1409-18. Tateishi H Campos CM Abdelghani M Leite RS Mangione JA Bary L Video densitometric assessment of aortic regurgitation after transcatheter aortic valve implantation results from the Brazilian TAVI registry EuroIntervention 2016 11 12 1409 1418 12 Abdelghani M, Tateishi H, Miyazaki Y, Cavalcante R, Soliman OI, Tijssen JG, et al. Angiographic assessment of aortic regurgitation by video-densitometry in the setting of TAVI: echocardiographic and clinical correlates. Catheter Cardiovasc Interv. 2017;90(4):650-9. Abdelghani M Tateishi H Miyazaki Y Cavalcante R Soliman OI Tijssen JG Angiographic assessment of aortic regurgitation by video-densitometry in the setting of TAVI echocardiographic and clinical correlates Catheter Cardiovasc Interv 2017 90 4 650 659 13 Nombela-Franco L, Barbosa Ribeiro H, Allende R, Urena M, Doyle D, Dumont E, et al. Role of balloon postdilation following trancatheter aortic valve implantation. Minerva Cardioangiol. 2013;61(5):499-512. Nombela-Franco L Barbosa Ribeiro H Allende R Urena M Doyle D Dumont E Role of balloon postdilation following trancatheter aortic valve implantation Minerva Cardioangiol 2013 61 5 499 512 14 Nombela-Franco L, Rodes-Cabau J, Delarochelliere R, Larose E, Doyle D, Villeneuve J, et al. Predictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve. JACC Cardiovasc Interv. 2012;5(5):499-512. Nombela-Franco L Rodes-Cabau J Delarochelliere R Larose E Doyle D Villeneuve J Predictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve JACC Cardiovasc Interv 2012 5 5 499 512 Minieditorial Novo Método Melhora a Avaliação do Grau de Regurgitação Aórtica durante TAVI por Aortografia Ribeiro Henrique B. Instituto do Coração de São Paulo - Universidade de São Paulo, São Paulo, SP - Brasil Correspondência: Henrique B. Ribeiro Instituto do Coração (InCor) de São Paulo, Universidade de São Paulo – Av. Dr. Eneas de Carvalho Aguiar, 55. CEP 05403-000, São Paulo, SP – Brasil E-mail: hbribeiro@gmail.com Palavras-chave Substituição da Valva Aórtica Transcateter/métodos Insuficiência da Valva Aórtica/mortalidade Insuficiência da Valva Aórtica/diagnóstico por imagem Ecocardiografia Tridimensional/métodos Aortografia/métodos

O implante transcateter de válvula aórtica (TAVI) é uma alternativa em rápida expansão à substituição cirúrgica da valva aórtica em pacientes considerados inoperáveis ou com risco operatório alto ou intermediário. Entretanto, a regurgitação aórtica residual (RA) secundária ao vazamento paravalvar (PVL) continua sendo uma limitação do procedimento.1 Embora a RA residual após a TAVI seja frequente, afetando até cerca de 70% dos pacientes tratados,2-4 ela pode ser de moderada a grave em aproximadamente 12% deles,4 ficando constantemente abaixo de 5% quando se utilizam dispositivos de geração atual, os quais possuem características específicas de vedação.1 Convém destacar que a RA moderada/grave apresenta impacto clínico negativo após o TAVI, com aumento de 3 vezes na mortalidade em 30 dias, e aumento de 2,3 vezes na mortalidade em 1 ano.4 Assim, sua avaliação e quantificação precisas por meio de uma abordagem multimodal são fundamentais para a utilização apropriada de procedimentos adicionais visando à redução da PVL, tais como pós-dilatação com balão (PDB), valve-in-valve ou oclusão percutânea do vazamento.1,5

Embora a ecocardiografia com Doppler tenha sido, até o momento, o método mais comum para avaliar a RA após o TAVI, sua quantificação precisa constitui um desafio, pois os jatos de RA são frequentemente múltiplos e excêntricos.3,5-7 Portanto, outros métodos para quantificação adequada da RA têm sido avaliados nos últimos anos, como a ecocardiografia 3D, o índice de RA hemodinâmico, a aortografia e até a ressonância magnética cardiovascular, cada um com suas vantagens e desvantagens específicas.1,5,7

Nesta edição da revista, Miyazaki et al.,8 investigaram uma avaliação angiográfica quantitativa da RA por videodensitometria (VD-AR) antes e depois da realização de PDB. A VD-AR produziu uma redução significativa de 24,0 [18,0 a 30,5]% para 12,0 [5,5 a 19,0]% (p < 0,001) após a PDB, com algum nível de melhora do grau de RA em até 70% dos pacientes tratados. É importante ressaltar que se observou uma RA significativa (VD-AR > 17%) em 47 pacientes (77%) antes, e em 19 pacientes (31%) após a PDB; além disso, em até um quarto deles, a VD-AR pré-PDB ficou abaixo de 17%, indicando que essa manobra adicional poderia ter sido evitada. O estudo tem suas limitações inerentes, como, por exemplo, o tamanho relativamente pequeno da coorte, a realização retrospectiva de seleção de pacientes e aquisição de imagens, e o fato de a decisão de realizar ou não a PDB ter ficado a critério dos operadores. Assim, o estudo compreende apenas casos em que a PDB foi considerada necessária, e foram selecionadas apenas aortografias com imagens de boa qualidade.

De modo notável, a técnica utilizada para quantificar a VD-AR constitui um novo método para determinar com precisão a fração de regurgitação em aortografias realizadas durante o TAVI; ela inclui a utilização de um software especializado e demonstrou excelentes reprodutibilidade e acurácia.9,10 Essa técnica oferece uma avaliação precisa da gravidade da PVL, e um índice de VD-AR maior do que 17% foi correlacionado ao aumento da mortalidade e ao remodelamento cardíaco reverso prejudicado após o TAVI.11,12 Embora as medições da VD-AR sejam realizadas apenas offline, já está em curso o desenvolvimento de uma avaliação on-line em tempo real, de modo a permitir que esse método ajude a guiar o TAVI em um futuro próximo. Isso porque a PDB é atualmente realizada em cerca de 10% a 20% dos pacientes após o TAVI, e reduz a gravidade da PVL em pelo menos um grau em mais de dois terços dos pacientes.13,14 No entanto, a PDB pode estar associada ao aumento do risco de eventos cerebrovasculares e lesão do anel valvar aórtico portanto, recomenda-se a utilização criteriosa desse procedimento.13,14

Em conclusão, uma vez que a PVL tem um impacto negativo nos desfechos clínicos após o TAVI, sua avaliação adequada por meio de uma abordagem integrativa multimodalidades e multiparamétrica é fundamental. Deve-se priorizar a prevenção da PVL pelo dimensionamento preciso do anel aórtico por meio de técnicas de imagem 3D, uso de dispositivos transcateter com características aprimoradas de vedação e posicionamento e dimensionamento ótimos do dispositivo. Ainda assim, se a PVL ocorrer após o TAVI, o cardiologista intervencionista pode considerar procedimentos corretivos, tais como a PDB, valve-in-valve ou a oclusão percutânea do vazamento periprotético. A nova técnica de VD-AR após o TAVI também permite avaliar quantitativamente a regurgitação pós-TAVI, e pode auxiliar nas decisões sobre realizar ou não a PDB, bem como determinar sua eficácia. Futuros estudos prospectivos são necessários para confirmar os presentes resultados.