Impact of device landing zone calcification on paravalvular regurgitation after transcatheter aortic valve replacement: A real-time three-dimensional transesophageal echocardiographic study

Background Determinants of paravalvular regurgitation after transcatheter aortic valve replacement (TAVR) remain unclear. The purpose of this study was to investigate the impact of aortic valve calcification (AVC) on paravalvular regurgitation after TAVR using real-time three-dimensional transesophageal echocardiography. Methods A total of 227 patients with severe aortic stenosis who underwent TAVR using the Edwards SAPIEN or SAPIEN XT valve were retrospectively analyzed. Severity of AVC was assessed on a visual scale ranging from 0 to 3 at the aortic annulus, the leaflets near the nadir, and the commissure. The shape of calcification was assessed by measuring the radial and circumferential lengths of annular calcification and by focusing on the calcification protruding into the left ventricular outflow tract from the annular level. Severity of paravalvular regurgitation was determined by the sum of the cross-sectional area of the vena contracta from two-dimensional or three-dimensional color Doppler transesophageal echocardiographic data. Significant paravalvular regurgitation was defined as at least a moderate grade. Results After excluding 25 patients with inadequate image quality of three-dimensional and color Doppler data for analysis, AVC could be evaluated in 202 patients. Significant paravalvular regurgitation was occurred in 37 patients (18%). The sum of the AVC scale at the annulus was significantly correlated with the grade of paravalvular regurgitation, while those at the leaflets near the nadir and the commissure were not. As assessed by receiver operating characteristic curve analysis, the radial and circumferential length of the annular calcification had good discriminatory ability for significant paravalvular regurgitation, with areas under the curve of 0.91 and 0.81, respectively. On multivariate analysis, annular calcification with radial length ≥ 3.0 mm, circumferential length ≥ 8.0 mm, and calcification protruding into the left ventricular outflow tract were independently associated with significant paravalvular regurgitation. Conclusions Assessment of AVC by real-time three-dimensional transesophageal echocardiography is feasible and has good discriminatory value for paravalvular regurgitation in patients who undergo TAVR. Significant paravalvular regurgitation after TAVR is associated with the location and size of calcification at the aortic annulus and left ventricular outflow tract, not with its severity.