Time-Integrated Aortic Regurgitation Index Helps Guide Balloon Postdilation During Transcatheter Aortic Valve Replacement and Predicts Survival

Background-Balloon postdilation (BPD) has emerged as an effective strategy to reduce paravalvular regurgitation (PVR) during transcatheter aortic valve replacement (TAVR). We investigated the utility of a time-integrated aortic regurgitation index (TIARI) to guide balloon postdilation (BPD) after valve deployment. Methods and Results-All consecutive patients who had echocardiography, aortography, and hemodynamic tracings recorded immediately after valve deployment during TAVR were included in the study. Catheter-derived invasive hemodynamic parameters were calculated offline. Among 157 patients who underwent TAVR, 49 (32%) patients required BPD to reduce significant PVR after valve deployment. Two experienced operators decided whether the patients required BPD for significant PVR. Median TIARI measured immediately after valve deployment was significantly lower in patients who required BPD when compared with patients who did not require BPD (P<0.001). In a multivariable analysis, lower TIARI (odds ratio: 0.81; P=0.003) and higher PVR grade on aortography and echocardiography (P<0.001 for both) were associated with BPD. Adding TIARI to echocardiography and aortographic PVR assessment resulted in a significant increase in global chi(2) (P<0.001), an integrated discrimination index of 9% (P=0.002), and combined C-statistics of 0.99 for predicting BPD. Higher TIARI after valve deployment was associated with better survival (hazard ratio: 0.94, P=0.014), while other hemodynamic and imaging parameters did not predict mortality after TAVR. Conclusions-Among patients undergoing TAVR, a TIARI measured immediately after valve deployment adds incremental value to guide BPD over aortography and echocardiography. Higher residual TIARI is associated with better survival after TAVR.