title: The role of cardiovascular magnetic resonance in stratifying paravalvular leak severity after transcatheter aortic valve replacement: an observational outcome study.
abstract: BACKGROUND
  Significant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis. Symptoms related to significant PVL may be difficult to differentiate from those related to other causes of heart failure. Cardiovascular magnetic resonance (CMR) directly quantifies valvular regurgitation, but has not been extensively studied in symptomatic post-TAVR patients.
  
  
  METHODS
  CMR was compared to qualitative (QE) and semi-quantitative echocardiography (SQE) for classifying PVL and prognostic value at one year post-imaging in 23 symptomatic post-TAVR patients. The primary outcome was a composite of all-cause death, heart failure hospitalization, and intractable symptoms necessitating repeat invasive therapy; the secondary outcome was a composite of all-cause death and heart failure hospitalization. The difference in event-free survival according to greater than mild PVL versus mild or less PVL by QE, SQE, and CMR were evaluated by Kaplan-Meier survival analysis.
  
  
  RESULTS
  Compared to QE, CMR reclassified PVL severity in 48% of patients, with most patients (31%) reclassified to at least one grade higher. Compared to SQE, CMR reclassified PVL severity in 57% of patients, all being reclassified to at least one grade lower; SQE overestimated PVL severity (mean grade 2.5 versus 1.7, p=0.001). The primary and secondary outcomes occurred in 48% and 35% of patients, respectively. Greater than mild PVL by CMR was associated with reduced event-free survival for the primary outcome (p<0.0001), however greater than mild PVL by QE and SQE were not (p=0.83 and p=0.068). Greater than mild PVL by CMR was associated with reduced event-free survival for the secondary outcome, as well (p=0.012).
  
  
  CONCLUSIONS
  In symptomatic post-TAVR patients, CMR commonly reclassifies PVL grade compared with QE and SQE. CMR provides superior prognostic value compared to QE and SQE, as patients with greater than mild PVL by CMR (RF>20%) had a higher incidence of adverse events.
authors.forename: Gregory R
authors.initials: GR
authors.lastname: Hartlage
authors.forename: Vasilis C
authors.initials: VC
authors.lastname: Babaliaros
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.forename: Salim
authors.initials: S
authors.lastname: Hayek
authors.forename: Christina
authors.initials: C
authors.lastname: Chrysohoou
authors.forename: Nima
authors.initials: N
authors.lastname: Ghasemzadeh
authors.forename: Arthur E
authors.initials: AE
authors.lastname: Stillman
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Clements
authors.forename: John N
authors.initials: JN
authors.lastname: Oshinski
authors.affiliation: Department of Medicine, Division of Cardiology, Structural Heart and Valve Center, Emory University School of Medicine, Atlanta, Georgia. sleraki@emory.edu.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001022:Aortic Valve Insufficiency / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D018572:Disease-Free Survival; D018618:Echocardiography, Doppler, Color; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D053208:Kaplan-Meier Estimate; D008279:Magnetic Resonance Imaging; D008297:Male; D010359:Patient Readmission; D011237:Predictive Value of Tests; D011475:Prosthesis Failure; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome