P251Predictors of aortic regurgitation after transcatheter aortic valve implantation : a 2D- and 3D-transoesophageal echocardiographic study in 135 patients

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Purpose: Transcatheter aortic valve implantation (TAVI) has been demonstrated to be a feasible and effective therapeutic alternative to traditional aortic valve replacement for high-risk surgical patients with symptomatic severe aortic stenosis. Despite improvements, post-procedural aortic regurgitation (AR) has still been described in a large number of patients receiving TAVI. In this study we aimed to examine the intraoperative 2D and 3D echocardiographic features associated with significant postprocedural para-prosthetic AR.Methods: 135 patients, aged 81 ± 7 years, were imaged by comprehensive 2D and 3D transoesophageal examinations immediately before and after TAVI. Various baseline factors were considered to develop a model for prediction of AR post-TAVI: aortic commissural and central calcifications, the "aortic annulus eccentricity index" calculated using the longest and shortest diameter in a 3D true cross sectional rendering (1- DAAlong/DAAshort), the "annulus-device mismatch" defined as the percentage difference between aortic annulus planimetered area and prosthesis expected area (1 - annulus area/device area), the aortic prosthesis overlapping with mitral valve anterior leaflet. Post-procedural AR was quantified according to standard echo-Doppler methods (score 0-4); we considered the AR significant if major than or equal to 2.Results: Successful valve deployment was obtained in all patients. The incidence of AR ≥ 2 was 21% (28/135) immediately after the procedure. The total amount of commissural calcifications and the calcification of the commissure between the right-coronary and non-coronary cusp were significantly (p<0.05) more frequent among subjects with AR; the annulus-device mismatch pre and post TAVI were significantly lower among patients with AR. Multivariate analysis revealed that the calcification of the commissure between the right-coronary and non-coronary cusp and the annulus-device mismatch post TAVI were the only independent predictors of the presence of AR.Conclusions: Intraoperative 2D and 3D transoesophageal echocardiography allows the identification of predictors of AR following successful TAVI. The identification of heavily calcified commissure between the right-coronary and non-coronary cusp and the measurement of annulus-device mismatch may lead to a better selection of patients and to improvements in prosthesis design and deployment in order to minimize operative complications such as significant AR

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