Association of Relative Left Ventricular Outflow Tract Area and Transcatheter Aortic Valve Replacement Related Paravalvular Leak

Background: Post-transcatheter aortic valve replacement (TAVR), paravalvular leak (PVL) is a quality metric associated with worse clinical outcomes. Transcatheter heart valve (THV) sizing is based primarily on the systolic annular size without regard to the left ventricular outflow tract (LVOT), which also lies within the THV landing zone. We hypothesized that LVOT size relative to the annulus is associated with post-TAVR PVL. Methods: Data from consecutive patients undergoing TAVR in a single high-volume center from January 2018 to March 2019 were used. Pre-TAVR data from multidetector computed tomography (MDCT) were collected. Relative LVOT area was defined as LVOT area/annular area during systole. Logistic regression analysis was used to evaluate association with post-TAVR mild or greater PVL by transthoracic echocardiography before discharge. Results: Among 293 patients (median age, 81.1 years; female, 49.5%; White, 88.0%), 81.6% received SAPIEN 3 and 18.4% received CoreValve THV models. Aortic valve morphology was bicuspid in 10.9% of patients. Prevalence of mild or greater PVL was 23.5% (mild in 20.1%). Relative LVOT area had a significant inverse association such that the odds of mild or greater PVL decreased significantly with every 1% increase in relative LVOT area (adjusted odds ratio, 0.96; 95% CI, 0.93-0.98; P = .002). There was no interaction between the type of implanted valve and the relative LVOT area. Patients in the highest relative LVOT tertile had significantly lower odds of mild or greater PVL (adjusted odds ratio, 0.42; 95% CI, 0.21-0.87; P = .018 vs first tertile). Conclusions: In patients undergoing TAVR with the newer generation of THV (SAPIEN 3 and CoreValve models), a relatively narrower LVOT area vs annular area was independently associated with increased odds of mild or greater PVL before discharge.