ABC | Volume 111, Nº2, August 2018

Original Article Arq Bras Cardiol. 2018; 111(2):193-202 Miyazaki et al Videodensitometry assessment of AR to guide TAVI in clinical practice (i.e. the minimalist approach) restricting the usage of transesophageal echocardiography (TEE) as a guidance for TAVI and increasing the role of aortography as a screening tool to determine the severity of PVL during the procedure. We have previously reported the in vitro and in vivo validation of quantitative angiographic assessment of aortic regurgitation (AR) by videodensitometry technique after implantation of THV with an excellent reproducibility and accuracy. 12 This technique provides an accurate assessment of the severity of PVL and it has been shown that a Videodensitometric- AR (VD-AR) > 17% correlates with increased mortality and impaired reverse cardiac remodelling as determined by echocardiography after TAVI. 13,14 This prognostic cut-off value (VD-AR > 17%) could have the potential to guide operators in deciding the need for BPD. However, the change of VD-AR from before to after BPD has not been investigated. The aim of this study is to assess a quantitative aortographic approach of PVL by videodensitometry before and after BPD. Methods Study design This is a report on patients enrolled in the the Brazilian TAVI registry including between January 2008 and January 2013. List of participating centers, inclusion and exclusion criteria and technical description of TAVI-procedure were previously reported. 15 The study protocol was approved by the ethics committee at each of the participating centers and all patients provided informed written consent. Three hundred ninety-nine patients were enrolled in the Brazilian TAVI registry in that period. VD-AR was performed and found to be analysable in 228 patients. 16 In this population, 102 patients underwent BPD, and in 17 cases, no angiography was available before BPD. Out of 85 cases with available aortograms before and after BPD, VD-AR was analysable at both time points in 61 cases (Figure 1). The reasons of non-analysable are discriminated in Figure 1. Aortographic assessment of AR Aortic root angiography was performed before and after BPD, using at least 20 ml of non-ionic contrast injected through a pigtail catheter positioned above the prosthetic valve stent (in case of a balloon-expandable device) or within the distal third of the prosthetic valve stent (in case of a self-expanding device). The decision on the total contrast volume and speed of injection, catheter size, and the projection were left to the discretion of the operators. Visual assessment of AR was performed by experienced observers based on Sellers’ grade. 17 In a blinded fashion, assessment of post-BPD aortograms was performed by observers different from those who analyzed pre-BPD aortograms. Quantification of AR using videodensitometric technology VD-AR before and after BPDwas analysed at an independent core laboratory (Cardialysis Clinical Trials Management and Core Laboratories, Rotterdam, the Netherlands) by experienced observers using a dedicated software (CAAS A-Valve 2.0.2; Pie Medical Imaging, Maastricht, The Netherlands). The details of this technique have been described elsewhere. 12-14,16,18 After drawing the contours of the aortic root ( i.e . reference region) and the subaortic one third of the left ventricle (i.e. region of interest [ROI]), the contrast time-density curves were generated for both regions over at least three cardiac cycles after contrast injection. The areas under these curves (AUC) are automatically calculated and represent the time-density integral. VD-AR is automatically calculated as the ratio of the AUC of the Figure 1 – Flowchart of this study. TAVI: transcatheter aortic valve implantation; VD-RA: Videodensitometric of aortic regurgitation; TEE: transesophageal echocardiography. Post TAVI VD-AR analyzable cases n = 228 Post-dilatation cases n = 102 Post-dilatation performed without aortography: 17 cases Post-dilatation performed with angiography, n = 85 Analyzable cases n = 61* (72%) Non-analyzable cases n = 24 (28%) Reasons of non-analysis • Contrast-filled descending aorta overlapping in the reference area or region of interest (n = 14) • Catheter in the LV (n = 4) • Table motion (n = 3) • Inadequate contrast (n = 2) • Short recording of aortography (n = 2) • TEE probe (n = 1) *Wire in LV: n = 49 194