Cardiac magnetic resonance for paravalvular leaks in post-transcatheter aortic valve replacement.

A n 80-year–old man with known coronary artery disease presented with progressively worsening shortness of breath over the past few weeks. On transthoracic echocar-diography (TTE) examination he was found to have severe aortic stenosis with an aortic valve area of 0.8 cm 2. Maximum aortic valve velocity was 4.25 m/s, peak gradient was 72.2 mm Hg with a mean gradient of 43.0 mm Hg, and mild aor-tic valve insufficiency was noted. He was deemed a surgical candidate and was randomly assigned to transcatheter aortic valve replacement (TAVR) as part of the Placement of Aortic Transcatheter Valve Trial II trial. An Edwards Sapien 29-mm XT bioprosthetic valve was placed through left-sided trans-femoral access uneventfully. Within a day of the procedure, the patient reported worsening dyspnea. A postprocedural TTE revealed mild anterior and posterior paravalvular leak (PVL) by color Doppler (Figure 1 and Movie I in the online-only Data Supplement). Given the clinical and imaging findings , a higher-grade PVL was suspected, prompting further evaluation with cardiac magnetic resonance (CMR) imaging. CMR 3-chamber view visualized the bioprosthesis, with phase contrast imaging identifying posterior PVL (Figure 2A and 2C and Movie II in the online-only Data Supplement). The anterior PVL was not well seen, likely because of the eccentricity of the jet and off-axis location. Short-axis CMR views are inappropriate for the evaluation of PVL because of significant artifact attributed to the metallic frame of the bioprosthetic valve. Paravalvular leak regurgitant fraction by flow quantifica-tion was 34% (grade 2, moderate; Figure 2E). The PVL was thought to be contributing to the patient's symptoms, and a decision was taken to proceed with valve-in-valve TAVR. Through right transfemoral access, a second Edwards Sapien 29-mm XT valve was deployed. Repeat CMR showed decrease of the posterior paravalvular PVL noted on the 3-chamber view (Figure 2B and 2D and Movie II in the online-only Data Supplement). CMR flow quantification showed significant reduction of PVL regurgitant fraction to 13.2% (grade 1, or mild; Figure 2F). By discharge, the patient's symptoms had improved, and a predischarge TTE showed an aortic valve area of 2.43 cm 2 with a maximum aor-tic velocity of 2.10 m/s, a peak gradient of 17.6 mm Hg with a mean gradient of 8.5 mm Hg, and only mild PVL. Discussion TAVR is accepted as standard of care for patients with inoperable severe aortic stenosis. It provides an alternative therapy to patients who are at high …