宇都宮 裕人¹, 三原 裕嗣², 板橋 裕史², 小林 さゆき², SIEGEL Robert², CHAKRAVARTY Tarun², JILAIHAWI Hasan², MAKKAR Raj², 塩田 隆弘²

Hiroto UTSUNOMIYA¹, Hirotsugu MIHARA², Yuji ITABASHI², Sayuki KOBAYASHI², Robert SIEGEL², Tarun CHAKRAVARTY², Hasan JILAIHAWI², Raj MAKKAR², Takahiro SHIOTA²

¹シーダーズ・サイナイ病院/広島大学病院循環器内科, ²シーダーズ・サイナイ病院循環器内科

¹Division of Cardiology, Cedars-Sinai Medical Center / Hiroshima University Hospital, ²Division of Cardiology, Cedars-Sinai Medical Center

キーワード :

【Aims】
Prosthesis-patient mismatch（PPM）after transcatheter aortic valve implantation（TAVI）leads to increased mortality. However, its peri-procedural determinants remain unknown. We investigated geometric changes in aortic annulus（AoA）and left ventricular outflow tract（LVOT）during TAVI by three-dimensional transesophageal echocardiography（3D-TEE）and its association with post-procedural PPM.
【Methods】
A total of 131 patients with severe aortic stenosis underwent intraprocedural 3D-TEE during balloon-expandable TAVI. The severity of PPM was graded using the indexed effective orifice area calculated by Doppler echocardiography at discharge, with moderate defined as≥0.65 and≤0.85 cm2/m2 and severe defined as＜0.65 cm2/m2.
【Results】
3D planimetered AoA area decreased after TAVI（P＜0.001）whereas the LVOT increased（P=0.004）. The eccentricity of both AoA and LVOT decreased after TAVI（both, P＜0.001）. At discharge, the incidence of overall and severe PPM was 44％and 12％，respectively. Patients with PPM had a larger body surface area（1.94±0.27 m2 vs. 1.77±0.24 m2，P＜0.001）, smaller aortic valve area（0.60±0.14 cm2 vs. 0.65±0.16 cm2，P=0.040）, and less frequent balloon dilation（81％versus 93％，P=0.033）. Despite similar area cover index, patients with PPM had a lower post-TAVI AoA area / pre-TAVI AoA area（91±8％vs. 95±7％，P=0.001）than those without PPM. The post-TAVI AoA area / pre-TAVI AoA area was independently associated with overall PPM（per 10％decrease: odds ratio, 1.80; 95％CI, 1.06-3.05; P=0.031）and severe PPM（per 10％decrease: odds ratio, 2.50; 95％CI, 1.05-5.36; P=0.04）. Additionally, a cut-off value of this ratio＞86.3％had a sensitivity of 84％and a specificity of 44％for the prevention of severe PPM.
【Conclusion】
3D-TEE can evaluate geometric changes in AoA and LVOT during balloon-expandable TAVI and predicts post-procedural PPM.