Application Of Echocardiography In The Complication After Transcatheter Aortic Valve Replacement

Background:Aortic valve disease is one of the common causes of heart valve surgery.In the past,patients with high surgical risk could not receive surgical aortic valve replacement and had to be treated with conservative drugs,leading to poor prognosis.Transcatheter aortic valve replacement(TAVR)has emerged as an alternative to traditional aortic valve replacement and has gradually become the standard of strategy for patients with high surgical risk or significant contraindications.After more than 10 years of development,TAVR has been proved to have the same safety and efficacy as surgical valve replacement,so the surgical indications began to expand to patients with low surgical risk.Considering the long-term survival time and quality of life of patients with low surgical risk,the common postoperative complications as paravalvular leakage(PVL)and conduction blocks(CBs)will have an important impact on the prognosis of patients.And bicuspid aortic valve(BAV),due to the heterogeneity of perivalvular structure,has different characteristics of postoperative complications compared with that of tricuspid aortic valve(TAV).Echocardiography plays an important role in the perioperative period of TAVR,such as accurately measuring of cardiac structure and function parameters before surgery,grading of the severity of aortic valve disease,real-time evaluation of surgical effects and complications during surgery,and postoperative evaluation of prosthetic valve function and the recovery of cardiac structure and function.Objective:Through retrospective analysis of perioperative data of patients underwent TAVR,BAV was used as the entry point to explore the risk factors of PVL and CBs,analyze their predictive value,and try to find the relationship between the characteristics of perivalvular structure and postoperative complications.Methods:1.Research in Risk Factors of Perivalvular Leakage After Transcatheter Aortic Valve Replacement in Bicuspid Aortic ValveRetrospective analysis was performed on patients who received TAVR for aortic valve disease in our hospital from January 2018 to December 2021.Patients with congenital heart disease,Marfan syndrome,connective tissue disease,previous aortic annulus surgery,poor echocardiographic images,and patients who underwent reoperation or died during perioperative period were excluded from the study.Demographic data,echocardiogram data and clinical surgical records were collected from the hospital medical record database.For the measurement of left ventricular outflow tract(LVOT)diameter,it was made approximately 3 to 10 mm from the Aortic annulus(AA)plane in mid-systole.LVOT morphology index=(LVOT diameter/AA diameter)×100%.The 1:1 propensity score matching analysis was performed to adjust the selection bias and possible imbalances in baseline characteristics between BAV and TAV groups.The propensity score for an individual was calculated according to the covariates of gender,age,body mass index,smoking,hypertension,hyperlipidemia,diabetes mellitus,coronary artery disease,atrial fibrillation,New York Heart Association functional class,operation pathway,valve function,left ventricular ejection fraction and Euroscore I.A caliper width of 0.035resulted in the best balances between homogeneity and retained sample size.Continuous data were expressed as mean±SD if they were normally distributed,or median value(Q_R)if not.Comparisons between the two groups were performed using t-tests for normally distributed variables or Mann–Whitney U-test for variables without normally distributed.Categorical data were presented as frequencies and percentages(%)and were compared using Pearson’sχ~2 test.Univariate logistic regression analysis was used to compare propensity score matching follow-up cohort in terms of their preoperative clinical characteristics.Candidate variables for the multivariable logistic regression analysis were required to have clinical relevance and p value<0.15.Multivariate logistic regression analysis was performed using Forward:LR model with entry criteria of p<0.05.Results were tabulated as odds ratios with 95%confidence intervals.The receiver operating curve(ROC)was used to observe the predictive value of echocardiography-related risk factors for moderate-to-severe PVL,Area under curve(AUC)was calculated.All statistical tests were two-tailed,with statistical significance when p<0.05.2.Research of echocardiographic risk factors for conduction blocks after transcatheter aortic valve replacementRetrospective analysis was performed on patients who received TAVR for aortic valve disease in our hospital from January 2018 to December 2021.Patients with baseline conduction block or PPI,congenital heart disease,hypertrophic cardiomyopathy,previous aortic annulus surgery,poor echocardiographic images,and patients who underwent reoperation or died during perioperative period were excluded from the study.Demographic data,echocardiogram data and clinical surgical records were collected from the hospital medical record database.LVOT morphology index was calculated as above.Continuous data were expressed as mean±SD if they were normally distributed,or median value(Q_R)if not.Comparisons between the two groups were performed using t-tests for normally distributed variables or Mann–Whitney U-test for variables without normally distributed.Categorical data were presented as frequencies and percentages(%)and were compared using Pearson’sχ~2 test.Multivariable logistic regression analysis was introduced to identify independent predictors of CBs.Candidate variables for the multivariable logistic regression analysis were required to have clinical relevance and p value<0.10.The OR with 95%CI were calculated.The receiver operating curve was used to observe the predictive value of echocardiography-related risk factors for CBs.For all tests,p value<0.05 was considered of statistical significance.Results:1.After propensity score matching,57 pairs of matching cohorts were selected and the baseline data of the 2 groups were balanced(all p>0.05).No significant differences were found in diameter of LVOT,AA,aortic sinus,transcatheter heart valve peak velocity and mean gradient between BAV group and TAV group(all p>0.05).There was no statistical difference in the incidence of intraoperative ventricular fibrillation,valve-in-valve,permanent pacemaker installation and acute cerebral infarction between the 2 groups(all p>0.05).The proportion of mild PVL in BAV group was not different from that in TAV group in statistic,but the proportion of moderate-to-severe PVL in BAV group was higher than that in TAV group significantly(p=0.026).Multivariate logistic regression analysis of PSM cohort showed that BAV(OR=6.103,95%CI:1.206～30.872,p=0.029)and LVOT shape index(OR=0.896,95%CI:0.817～0.982,p=0.019)were positively correlated with moderate-to-severe PVL.Then,multivariate logistic regression analysis of PSM cohort showed that BAV(OR=6.103,95%CI:1.206～30.872,p=0.029)and LVOT shape index(OR=0.896,95%CI:0.817～0.982,p=0.019)were positively correlated with moderate-to-severe PVL.The receiver operating curve showed that the LVOT shape index could predict the occurrence of moderate-to-severe PVL after TAVR in BAV patients(AUC=0.744,95%CI:0.602～0.886,p=0.021).2.Of the 339 patients,217 patients(64.0%)were designated as none-CBs,and 122patients(36.0%)were classified into the CBs group.The differences in echocardiographic indices of LVOT shape index,valve type and intraoperative surgical access between patients in the blocked and unblocked groups were statistically significant(all p<0.05).The results of the multifactorial logistic regression model suggested that the LVOT shape index(OR=1.088,95%CI:1.051～1.125,p<0.001),valve type(bicuspid aortic valve)(OR=0.211,95%CI:0.097～0.458,p<0.001),surgical access(transfemoral)(OR=2.433,95%CI:1.498to 3.950,p<0.001)were independent risk factors for CBs after TAVR.The receiver operating curve showed that the LVOT shape index predicted the development of CBs after TAVR(AUC=0.677,95%CI:0.619～0.735,p<0.001),with a cut-off value of 104.7%and sensitivity of 67.2%and specificity of 64.1%.The receiver operating curve showed also that the LVOT shape index predicted the development of PVL after TAVR(AUC=0.666,95%CI:0.609～0.724,p<0.001),with a cut-off value of 103.8%and sensitivity of54.5%and specificity of 77.3%.Conclusion:1.Compared with the TAV patients,BAV patients are more likely to develop moderate-to-severe PVL after TAVR.LVOT shape index is an independent risk factor for moderate-to-severe PVL after TAVR in BAV and TAV patients,and it could be only used to predict the occurrence of moderate-to-severe PVL in BAV patients.2.LVOT morphology index,transfemoral pathway and TAV emerged as predictors of CBs after TAVR,and LVOT morphology index has certain predictive value.The optimal range of LVOT morphology index is approximately 103.8%～104.7%to minimize the incidence of both CBs and PVL in the same time.