Integrated Severity Staging of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation Using Echocardiographic and Hemodynamic Assessment

Evidence suggests that even mild-to-moderate paravalvular regurgitation (PVR) following transcatheter aortic valve implantation (TAVI) is associated with adverse outcomes. We directly compared the diagnostic performance and predictive value of invasive (hemodynamic) versus noninvasive (echocardiographic) assessments of PVR. Additionally, we explored the effectiveness of a comprehensive integrated approach that combines both methodologies to accurately identify and predict the clinical consequences of PVR. This retrospective, single-center, observational study included 126 patients with PVR after TAVI. PVR severity was assessed through both invasive (Aortic Regurgitation Index – ARI - and ARIratio) and noninvasive metrics. Additionally, an integrated PVR staging system was developed, incorporating both methodologies and classifying patients into mild, moderate or severe categories. The prognostic significance of this integrated staging approach was also evaluated, particularly concerning major adverse cardiovascular events (MACE) at the latest clinical follow-up. Our findings revealed a poor agreement between hemodynamic assessments and noninvasive evaluation (Cohen's Kappa = 0.24) particularly in cases graded invasively as mild and subsequently reclassified via echocardiographic metrics. The integrated PVR staging demonstrated superior diagnostic accuracy compared to the invasive method (AUC 0.805 vs 0.660 respectively, De Long p = 0.020) while showing comparable accuracy to noninvasive staging (AUC 0.750 p = 0.357). However, invasive assessment was more effective in predicting early MACE, whereas noninvasive method provided a better accuracy in evaluating late events. Moreover, patients with severe PVR identified through the integrated assessment had significantly lower event-free survival (log-rank chi-square 31.97, p <0.001). In conclusion, invasive assessment of PVR effectively identifies patients at risk for early MACE, particularly those with moderate or severe PVR. However, echocardiography significantly enhances risk stratification in all other cases. Therefore, an integrated approach combining both invasive and noninvasive modalities may represent the most appropriate strategy for identifying patients at increased risk of adverse outcomes following TAVI.