title: Paravalvular Regurgitation after Transcatheter Aortic Valve Replacement: Comparing Transthoracic versus Transesophageal Echocardiographic Guidance.
abstract: Transcatheter aortic valve replacement (TAVR) is increasingly being performed in cardiac catheterization laboratories using transthoracic echocardiography (TTE) to guide valve deployment. The risk of paravalvular regurgitation (PVR) remains a concern.
  
  
  
  We retrospectively reviewed 454 consecutive patients (mean age, 82 ± 8; 58% male) who underwent transfemoral TAVR at Emory Healthcare from 2007 to 2014. Two hundred thirty-four patients underwent TAVR in the cardiac catheterization laboratory with TTE guidance (TTE-TAVR; mean Society of Thoracic Surgeons score, 10%), while 220 patients underwent the procedure in the hybrid operating room with transesophageal echocardiography (TEE) guidance (TEE-TAVR; mean Society of Thoracic Surgeons score, 11%). All patients received an Edwards valve (SAPIEN 55%, SAPIEN-XT 45%). Clinical and procedural characteristics, echocardiographic parameters, and incidence of PVR were compared.
  
  
  
  The incidence of at least mild PVR at discharge was comparable between TTE-TAVR and TEE-TAVR (33% vs 38%, respectively; P = .326) and did not differ when stratified by valve type. However, in the TTE-TAVR group, there was a higher incidence of second valve implantation (7% vs 2%; P = .026) and postdilation (38% vs 17%; P < .001) during the procedure. Although not independently associated with PVR at discharge (odds ratio = 1.12; 95% CI, 0.69-1.79), TTE-TAVR was associated with PVR-related events: the combined outcome of mild PVR at discharge, intraprocedural postdilation, and second valve insertion (odds ratio = 1.58; 95% CI, 1.01-2.46). There were no significant differences in PVR at 30 days, 6 months, and 1 year between the two groups.
  
  
  
  TTE-TAVR in a high-risk group of patients was associated with increased incidence of intraprocedure PVR-related events, although it was not associated with higher rates of PVR at follow-up. Multicenter randomized trials are required to confirm the cost-effectiveness and safety of TTE-TAVR.
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Salim S
authors.initials: SS
authors.lastname: Hayek
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Frank E
authors.initials: FE
authors.lastname: Corrigan
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Jose F
authors.initials: JF
authors.lastname: Condado
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Shuang
authors.initials: S
authors.lastname: Lin
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Sharon
authors.initials: S
authors.lastname: Howell
authors.affiliation: Division of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: James P
authors.initials: JP
authors.lastname: MacNamara
authors.affiliation: Cleveland Clinic, Cleveland, Ohio.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Spilias
authors.affiliation: Department of Bioinformatics, Emory University, Atlanta, Georgia.
authors.forename: Shuai
authors.initials: S
authors.lastname: Zheng
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Patricia
authors.initials: P
authors.lastname: Keegan
authors.affiliation: Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Vinod
authors.initials: V
authors.lastname: Thourani
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Vasilis C
authors.initials: VC
authors.lastname: Babaliaros
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia. Electronic address: stam_lerakis@emoryhealthcare.org.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
mesh_terms: D000369:Aged, 80 and over; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000517:prevention & control; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000601:surgery*; D015984:Causality; D015897:Comorbidity; D004452:Echocardiography / Q000706:statistics & numerical data; D017548:Echocardiography, Transesophageal / Q000706:statistics & numerical data*; D005260:Female; D005845:Georgia / Q000453:epidemiology; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000517:prevention & control; D012086:Reoperation / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D025321:Surgery, Computer-Assisted / Q000706:statistics & numerical data; D015996:Survival Rate; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data*; D016896:Treatment Outcome
keywords: Minimalist; Paravalvular regurgitation; Transcatheter aortic valve replacement; Transesophageal echocardiography