Incidence, Mechanisms, and Predictors of Mean Systolic Gradients ≥20 mm Hg after Transcatheter Aortic Valve Implantation

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There is a significant increase in transvalvular gradients after transcatheter aortic valve implantation (TAVI) in some patients; however, mechanisms underlying the greater than expected gradients are unknown. We sought to determine the incidence and mechanisms of greater than expected gradients post-TAVI. A total of 424 patients who underwent TAVI at our institution between November 2008 and August 2015 and had at least 1 follow-up echocardiogram were included in the study. Greater than expected gradients were defined as mean systolic Doppler gradients ≥20 mm Hg. The primary end-point was incidence and mechanisms of mean systolic Doppler gradients ≥20 mm Hg. A total of 36 (8%) patients had mean systolic Doppler gradients ≥20 mm Hg. The mechanisms of mean systolic Doppler gradients ≥20 mm Hg were: patient prosthesis mismatch in 15 (42%) patients, high cardiac output in 13 (36%), prosthetic and periprosthetic regurgitation in 11 (31%), stenosis in 5 (14%), and multiple mechanisms in 8 (22%). Patients with mean systolic Doppler gradients ≥20 mm Hg had higher cardiac re-hospitalization rate, but no difference in mortality or major cardiovascular events when compared with the normal gradient group. Smaller prosthetic valve size (p <0.0001) and larger body mass index (p = 0.02) were associated with mean systolic Doppler gradients ≥20 mm Hg; warfarin therapy at discharge had no effect on gradients. In conclusion, about 8% patients had mean systolic Doppler gradients ≥20 mm Hg following TAVI, and patient-prosthesis mismatch was the most common mechanism. The mean systolic Doppler gradients ≥20 mm Hg after TAVI are not benign and warrant careful surveillance.

Section snippets

Methods

The study was approved by the Mayo Clinic Institutional Review Board. All patients undergoing TAVI at Mayo Clinic, Minnesota between November 2008 and August 2015 who had at least 1 transthoracic echocardiogram (TTE) at Mayo Clinic after TAVI were considered for the study. Patients who had valve-in-valve procedure and those who followed-up at different institutions were excluded from the analysis. Baseline demographic data, TAVI procedural details (type and size of TAV, implantation route,

Results

A total of 621 patients underwent TAVI at our institution during the study period. Of these, 424 patients who had TAVI in native valve and baseline (predischarge) and at least 1 follow-up TTE at our institution were included in the study; 37% had 3 or more echocardiograms during follow-up. The reasons for exclusion were: valve-in-valve procedure (n = 114), post-TAVI TTE not performed because of death before 1st-month follow-up (n = 18), SAVR (n = 1), and patient having a follow-up at different

Discussion

The major findings of our study are the following: (1) the incidence of mean systolic Doppler gradients ≥20 mm Hg post-TAVI was 8% and nearly 22% of patients had more than 1 mechanism of mean systolic Doppler gradients ≥20 mm Hg; (2) the most common mechanisms in order of frequency were patient prosthesis mismatch, high cardiac output, prosthetic and periprosthetic regurgitation (more than mild) and stenosis; (3) patients with baseline mean systolic Doppler gradients ≥20 mm Hg (on predischarge

Disclosures

Nothing relevant to disclose.

Acknowledgement

None.

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