title: Pre-Procedural Hemodynamic Status Improves the Discriminatory Value of the Aortic Regurgitation Index in Patients Undergoing Transcatheter Aortic Valve Replacement.
abstract: OBJECTIVE
  The aims of this study were to increase the discriminatory value of the aortic regurgitation index (ARI) for the assessment of paravalvular regurgitation (PVR) and to further elucidate the association between aortic regurgitation severity and mortality after transcatheter aortic valve replacement (TAVR).
  
  
  BACKGROUND
  Hemodynamic parameters such as the ARI complement predominantly angiographically guided TAVR. However, the ARI depends on several baseline and periprocedural characteristics.
  
  
  METHODS
  The ARI was prospectively calculated before and after TAVR in 600 patients. The severity of PVR was assessed in all patients by angiography and echocardiography according to a 3-class scheme. To account for pre-procedural hemodynamic status, the ARI ratio was calculated as post- over pre-procedural ARI.
  
  
  RESULTS
  Apart from the degree of PVR (β = -0.396, p < 0.001), pre-procedural hemodynamic status in the form of the ARI before TAVR (β = 0.227, p < 0.001) was associated with post-procedural ARI in multivariate regression analysis. The ARI ratio increased the specificity of post-procedural ARI alone for the prediction of both more than mild PVR and 1-year mortality from 75.1% to 93.2% and from 75.0% to 93.3%, respectively. Patients with post-procedural ARI values <25 after TAVR had significantly increased 1-year mortality only when the ARI ratio was <0.60 (50.0% vs. 26.3%, p = 0.001).
  
  
  CONCLUSIONS
  The ARI ratio integrating pre- and post-procedural hemodynamic status increases the discriminatory value of post-procedural ARI. The ARI ratio, which reflects acute hemodynamic changes after TAVR, is useful to identify patients with negative outcomes.
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany. Electronic address: jan-malte.sinning@ukb.uni-bonn.de.
authors.forename: Jan-Malte
authors.initials: JM
authors.lastname: Sinning
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Anja
authors.initials: A
authors.lastname: Stundl
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Simon
authors.initials: S
authors.lastname: Pingel
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Marcel
authors.initials: M
authors.lastname: Weber
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Sedaghat
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Hammerstingl
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Mariuca
authors.initials: M
authors.lastname: Vasa-Nicotera
authors.affiliation: Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany.
authors.forename: Fritz
authors.initials: F
authors.lastname: Mellert
authors.affiliation: Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Schiller
authors.affiliation: Department of Cardiology, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; NIHR Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, United Kingdom.
authors.forename: Jan
authors.initials: J
authors.lastname: Kovac
authors.affiliation: Heart Center Bonn, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany.
authors.forename: Armin
authors.initials: A
authors.lastname: Welz
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Eberhard
authors.initials: E
authors.lastname: Grube
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Nikos
authors.initials: N
authors.lastname: Werner
authors.affiliation: Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
authors.forename: Georg
authors.initials: G
authors.lastname: Nickenig
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D003661:Decision Support Techniques; D016002:Discriminant Analysis; D004452:Echocardiography; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D008297:Male; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011474:Prosthesis Design; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: AR index; TAVI; TAVR; aortic stenosis; hemodynamic status; paravalvular leakage; paravalvular regurgitation