Transcatheter Aortic Valve Replacement (TAVR)

Early Detection of Paravalvular Leakage in TAVR Implants

Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI) has become a common alternative to surgical aortic valve replacement for patients with severe aortic valve stenosis and a high level of surgical risk. However, twenty percent of TAVR implants show paravalvular leakage, which is impossible to detect with Echo[1]. With pressure volume (PV) monitoring, this leakage can be detected during the isovolumetric relaxation phase. Moreover, acute paravalvular leakage will immediately shift the left ventricular PV plane to the right due to acute volume overloading. The newest generation of percutaneous valves can be repositioned mid-procedure, which may in combination with PV analysis, result in optimal valve placement with minimal or no paravalvular leakage.

Recent clinical work suggests that LV function monitoring by PV loops throughout the TAVR procedure is feasible and may improve the TAVR treatment by providing an unprecedented detailed real-time insight of cardiac performance prior, during and after the valve replacement.

There are two options available for placing the PV catheter. Trans-septal catheter introduction allows LV function monitoring throughout the TAVR procedure. Placing the catheter retrograde across the aortic valve allows measurement of the pressure gradient across the valve and evaluation of LV function prior to and immediately after valve replacement.

In the example below, the PV loops prior to the procedure show a large aortic  valve pressure gradient with moderately impaired LV systolic function. Immediatelyafter the TAVR, the LV pressure decreases and the PV loops shift to the left and the diastolic PV plane shifts down. The PV loops also show evidence  of some modest aortic regurgitation (AR) during isovolumetric relaxation.

PV Loops Pre and Post TAVR

References

1. Genereux P et al. Paravalvular leak after transcatheter aortic valve replacement. J Am Coll Cardiol 2013;61:1125-36.

2. Sinning J-M et al. Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol. 2013;62(1):11-20.