Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://cr.elmerpub.com

Original Article

Volume 16, Number 4, August 2025, pages 312-320

Increase in Aortic Valve Mean Gradients One Day After Transcatheter Aortic Valve Implantation: The Role of Mitral Regurgitation

Figure 1. Change in transvalvular mean gradient across time for patients with no-to-mild MR and patients with moderate-to-severe MR. MR: mitral regurgitation; TAVI: transcatheter aortic valve implantation.

Figure 2. Change in transvalvular max gradient across time for patients with no-to-mild MR and patients with moderate-to-severe MR. MR: mitral regurgitation; TAVI: transcatheter aortic valve implantation.

**Table 1.** Comparing Baseline Clinical Characteristics Between Patients With No-to-Mild MR and Patients With Moderate-to-Severe MR
Baseline clinical characteristics of the patients	No-to-mild MR (n = 327)	Moderate-to-severe MR (n = 51)	P value
Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. BMI: body mass index; CABG: coronary artery bypass grafting; COPD: chronic obstructive pulmonary disease; MR: mitral regurgitation; NYHA: New York Heart Association; TAVI: transcatheter aortic valve implantation; TIA: transient ischemic attack; IQR: interquartile range.
Age (years)	77 (71 - 84)	79 (76 - 85)	0.01
Gender (male)	177 (54.1%)	29 (56.9%)	0.01
Clinical history
Diabetes mellitus	160 (48.9%)	22 (43.1%)	0.44
Hypertension	292 (89.3%)	48 (94.1%)	0.29
Hyperlipidemia	270 (82.6%)	40 (78.4%)	0.47
Peripheral vascular disease	102 (31.2%)	15 (29.4%)	0.80
Stroke/TIA	54 (16.5%)	14 (27.5%)	0.06
COPD	72 (22%)	10 (19.6%)	0.70
Atrial fibrillation	102 (31.2%)	23 (45.1%)	0.05
Previous permanent pacemaker	38 (11.6%)	10 (19.6%)	0.11
Chronic kidney disease	155 (47.4%)	33 (64.7%)	0.02
Coronary artery disease	210 (64.2%)	35 (68.6%)	0.54
Previous myocardial infarction	72 (22%)	8 (15.7%)	0.30
Previous CABG	64 (19.6%)	20 (39.2%)	0.002
Obstructive sleep apnea	70 (21.4%)	7 (13.7%)	0.21
BMI (kg/m²)	29 (25 - 34.7)	26.37 (23.96 - 30)	0.002
NYHA class III-IV symptoms	309 (94.8%)	48 (94.1%)	0.96
CHA2DS2-VASc score	4 (4 - 5)	5 (4 - 6)	0.002
Type of TAVI valve
SAPIEN	34 (10.4%)	9 (17.6%)	0.19
SAPIEN XT	3 (0.9%)	2 (3.9%)	0.19
SAPIEN 3	286 (87.5%)	40 (78.5%)	0.19
SAPIEN 3 Ultra	4 (1.2%)	0	0.19

Table 1. Comparing Baseline Clinical Characteristics Between Patients With No-to-Mild MR and Patients With Moderate-to-Severe MR

Baseline clinical characteristics of the patients

No-to-mild MR (n = 327)

Moderate-to-severe MR (n = 51)

P value

Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. BMI: body mass index; CABG: coronary artery bypass grafting; COPD: chronic obstructive pulmonary disease; MR: mitral regurgitation; NYHA: New York Heart Association; TAVI: transcatheter aortic valve implantation; TIA: transient ischemic attack; IQR: interquartile range.

Age (years)

77 (71 - 84)

79 (76 - 85)

0.01

Gender (male)

177 (54.1%)

29 (56.9%)

0.01

Clinical history

Diabetes mellitus

160 (48.9%)

22 (43.1%)

0.44

Hypertension

292 (89.3%)

48 (94.1%)

0.29

Hyperlipidemia

270 (82.6%)

40 (78.4%)

0.47

Peripheral vascular disease

102 (31.2%)

15 (29.4%)

0.80

Stroke/TIA

54 (16.5%)

14 (27.5%)

0.06

COPD

72 (22%)

10 (19.6%)

0.70

Atrial fibrillation

102 (31.2%)

23 (45.1%)

0.05

Previous permanent pacemaker

38 (11.6%)

10 (19.6%)

0.11

Chronic kidney disease

155 (47.4%)

33 (64.7%)

0.02

Coronary artery disease

210 (64.2%)

35 (68.6%)

0.54

Previous myocardial infarction

72 (22%)

8 (15.7%)

0.30

Previous CABG

64 (19.6%)

20 (39.2%)

0.002

Obstructive sleep apnea

70 (21.4%)

7 (13.7%)

0.21

BMI (kg/m²)

29 (25 - 34.7)

26.37 (23.96 - 30)

0.002

NYHA class III-IV symptoms

309 (94.8%)

48 (94.1%)

0.96

CHA2DS2-VASc score

4 (4 - 5)

5 (4 - 6)

0.002

Type of TAVI valve

SAPIEN

34 (10.4%)

9 (17.6%)

0.19

SAPIEN XT

3 (0.9%)

2 (3.9%)

0.19

SAPIEN 3

286 (87.5%)

40 (78.5%)

0.19

SAPIEN 3 Ultra

4 (1.2%)

0.19

**Table 2.** Comparing Various Factors Considered to Be Low-Flow State Inducers Between Patients With No-to-Mild MR and Patients With Moderate-to-Severe MR
Low-flow state factors	No-to-mild MR (n = 327)	Moderate-to-severe MR (n = 51)	P value
Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. MR: mitral regurgitation; TAVI: transcatheter aortic valve implantation; IQR: interquartile range.
Volume status
Pre-TAVI weight (kg)	83.9 (71 - 99.2)	75.7 (65.8 - 88.3)	0.005
Post-TAVI weight (kg)	84.1 (70.48 - 100)	76.2 (65 - 90)	0.006
Pre-TAVI systolic blood pressure (mm Hg)	155 (139 - 173)	146 (129 - 163.5)	0.055
Pre-TAVI diastolic blood pressure (mm Hg)	67 (59 - 76.5)	64 (55 - 74.5)	0.175
Immediate post-TAVI systolic blood pressure (mm Hg)	126 (114 - 141.5)	130 (118.5 - 139}	0.62
Immediate post-TAVI diastolic blood pressure (mm Hg)	54 (47 - 62.5)	54 (46 - 63.5)	0.813
24-h post-TAVI systolic blood pressure (mm Hg))	127 (115 - 138)	124 (118 - 139)	0.664
24-h post-TAVI diastolic blood pressure (mm Hg))	57 (50 - 65)	56 (46 - 64.5)	0.451
Peri-procedural fluids (mL)	575 (200 - 800)	550 (125.5 - 950)	0.411
Post-procedural fluids (mL)	394 (0 - 970)	450 (0 - 1,050)	0.869
Medications
Total fentanyl dose (mg)	100 (50 - 250)	100 (50 - 250)	0.733
Total propofol dose (g)	0	0	0.945
Total versed dose (g)	1 (0 - 2)	1 (0 - 2)	0.587
Total dexmedetomidine dose (µg)	16.8 (0 - 83.35)	26.5 (0 - 63.45)	0.669

Table 2. Comparing Various Factors Considered to Be Low-Flow State Inducers Between Patients With No-to-Mild MR and Patients With Moderate-to-Severe MR

Low-flow state factors

No-to-mild MR (n = 327)

Moderate-to-severe MR (n = 51)

P value

Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. MR: mitral regurgitation; TAVI: transcatheter aortic valve implantation; IQR: interquartile range.

Volume status

Pre-TAVI weight (kg)

83.9 (71 - 99.2)

75.7 (65.8 - 88.3)

0.005

Post-TAVI weight (kg)

84.1 (70.48 - 100)

76.2 (65 - 90)

0.006

Pre-TAVI systolic blood pressure (mm Hg)

155 (139 - 173)

146 (129 - 163.5)

0.055

Pre-TAVI diastolic blood pressure (mm Hg)

67 (59 - 76.5)

64 (55 - 74.5)

0.175

Immediate post-TAVI systolic blood pressure (mm Hg)

126 (114 - 141.5)

130 (118.5 - 139}

0.62

Immediate post-TAVI diastolic blood pressure (mm Hg)

54 (47 - 62.5)

54 (46 - 63.5)

0.813

24-h post-TAVI systolic blood pressure (mm Hg))

127 (115 - 138)

124 (118 - 139)

0.664

24-h post-TAVI diastolic blood pressure (mm Hg))

57 (50 - 65)

56 (46 - 64.5)

0.451

Peri-procedural fluids (mL)

575 (200 - 800)

550 (125.5 - 950)

0.411

Post-procedural fluids (mL)

394 (0 - 970)

450 (0 - 1,050)

0.869

Medications

Total fentanyl dose (mg)

100 (50 - 250)

0.733

Total propofol dose (g)

0.945

Total versed dose (g)

1 (0 - 2)

0.587

Total dexmedetomidine dose (µg)

16.8 (0 - 83.35)

26.5 (0 - 63.45)

0.669

**Table 3.** Comparing Echocardiographic Characteristics Between Patients With No-to-Mild MR and Patients With Moderate-to-Severe MR
Echocardiographic characteristics of the patients	No-to-mild MR (n = 327)	Moderate-to-severe MR (n = 51)	P value
Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. MR: mitral regurgitation; TAVI: transcatheter aortic valve implantation; IQR: interquartile range.
Pre-TAVI
Left ventricular ejection fraction (%)	58 (55 - 62.5)	51 (45 - 57.1)	< 0.001
Aortic valve area (cm²)	0.78 (0.66 - 0.90)	0.77 (0.69 - 0.85)	0.002
Aortic valve mean gradient (mm Hg)	41.1 (32.9 - 48.11)	34.5 (24.3 - 45)	0.017
Immediate post-TAVI
Transvalvular mean gradient (mm Hg)	4.5 (3 - 6)	3.3 (2.5 - 4.7)	< 0.001
Transvalvular peak gradient (mm Hg)	9.4 (7 - 13)	7 (5.9 - 10)	< 0.001
24-h post-TAVI
Transvalvular mean gradient (mm Hg)	11 (8 - 14.7)	9.05 (7 - 13)	< 0.001
Transvalvular peak gradient (mm Hg)	22 (16.3 - 29.1)	18 (13.4 - 24.3)	< 0.001
Deltas (24-h - immediate)
Transvalvular mean gradient delta (mm Hg)	6 (3.7 - 9)	6 (3.4 - 9)	0.87
Transvalvular peak gradient delta (mm Hg)	12.2 (6.8 - 18)	12 (5.5 - 15.9)	0.41

Table 3. Comparing Echocardiographic Characteristics Between Patients With No-to-Mild MR and Patients With Moderate-to-Severe MR

Echocardiographic characteristics of the patients

No-to-mild MR (n = 327)

Moderate-to-severe MR (n = 51)

P value

Pre-TAVI

Left ventricular ejection fraction (%)

58 (55 - 62.5)

51 (45 - 57.1)

< 0.001

Aortic valve area (cm²)

0.78 (0.66 - 0.90)

0.77 (0.69 - 0.85)

0.002

Aortic valve mean gradient (mm Hg)

41.1 (32.9 - 48.11)

34.5 (24.3 - 45)

0.017

Immediate post-TAVI

Transvalvular mean gradient (mm Hg)

4.5 (3 - 6)

3.3 (2.5 - 4.7)

< 0.001

Transvalvular peak gradient (mm Hg)

9.4 (7 - 13)

7 (5.9 - 10)

< 0.001

24-h post-TAVI

Transvalvular mean gradient (mm Hg)

11 (8 - 14.7)

9.05 (7 - 13)

< 0.001

Transvalvular peak gradient (mm Hg)

22 (16.3 - 29.1)

18 (13.4 - 24.3)

< 0.001

Deltas (24-h - immediate)

Transvalvular mean gradient delta (mm Hg)

6 (3.7 - 9)

6 (3.4 - 9)

0.87

Transvalvular peak gradient delta (mm Hg)

12.2 (6.8 - 18)

12 (5.5 - 15.9)

0.41

**Table 4.** Quantitative Echocardiographic Measurements of MR Before and After TAVI, Stratified by MR Severity Groups
MR severity quantification by TTE	Pre-TAVI	Post-TAVI	P value
Quantitative metrics include MR vena contracta, EROA measured by both PISA and continuity methods, and regurgitant volume. In the no-to-mild MR group, quantitative values are uniformly reported below ASE guideline-based thresholds for moderate MR due to the absence of sufficiently measurable MR jets, a limitation inherent to the minimal severity in this cohort. As such, statistical comparisons are not applicable for this group. In contrast, patients with moderate-to-severe MR demonstrated significant reductions in all quantitative parameters post-TAVI. Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. EROA: effective regurgitant orifice area; TTE: transthoracic echocardiogram; MR: mitral regurgitation; PISA: proximal isovelocity surface area; TAVI: transcatheter aortic valve implantation; ASE: American Society of Echocardiography; IQR: interquartile range.
No-to-mild MR patients (n = 327)
MR vena contracta (cm)	< 0.30	< 0.30	-
MR EROA - PISA (cm²)	< 0.20	< 0.20	-
MR EROA - continuity (cm²)	< 0.20	< 0.20	-
Regurgitant volumes (mL)	< 30	< 30	-
Moderate-to-severe MR patients (n = 51)
MR vena contracta (cm)	0.50 (0.41 - 0.71)	0.3 (0.30 - 0.30)	< 0.001
MR EROA - PISA (cm²)	0.40 (0.34 - 0.57)	0.20 (0.20 - 0.20)	< 0.001
MR EROA - continuity (cm²)	0.41 (0.35 - 0.61)	0.20 (0.20 - 0.20)	< 0.001
Regurgitant volumes (mL)	73.94 (58.26 - 114.61)	30 (30 - 30)	< 0.001

Table 4. Quantitative Echocardiographic Measurements of MR Before and After TAVI, Stratified by MR Severity Groups

MR severity quantification by TTE

Pre-TAVI

Post-TAVI

P value

Quantitative metrics include MR vena contracta, EROA measured by both PISA and continuity methods, and regurgitant volume. In the no-to-mild MR group, quantitative values are uniformly reported below ASE guideline-based thresholds for moderate MR due to the absence of sufficiently measurable MR jets, a limitation inherent to the minimal severity in this cohort. As such, statistical comparisons are not applicable for this group. In contrast, patients with moderate-to-severe MR demonstrated significant reductions in all quantitative parameters post-TAVI. Data are expressed as median (IQR, 25th - 75th percentile) or proportion (percentages). P < 0.05 indicates the difference between the two groups is statistically significant. EROA: effective regurgitant orifice area; TTE: transthoracic echocardiogram; MR: mitral regurgitation; PISA: proximal isovelocity surface area; TAVI: transcatheter aortic valve implantation; ASE: American Society of Echocardiography; IQR: interquartile range.

No-to-mild MR patients (n = 327)

MR vena contracta (cm)

< 0.30

MR EROA - PISA (cm²)

< 0.20

MR EROA - continuity (cm²)

< 0.20

Regurgitant volumes (mL)

< 30

Moderate-to-severe MR patients (n = 51)

MR vena contracta (cm)

0.50 (0.41 - 0.71)

0.3 (0.30 - 0.30)

< 0.001

MR EROA - PISA (cm²)

0.40 (0.34 - 0.57)

0.20 (0.20 - 0.20)

< 0.001

MR EROA - continuity (cm²)

0.41 (0.35 - 0.61)

0.20 (0.20 - 0.20)

< 0.001

Regurgitant volumes (mL)

73.94 (58.26 - 114.61)

30 (30 - 30)

< 0.001