What really drives gradients after TAVR-in-TAVR—and do they actually matter?

In this conversation, Dr. Amr Abbas and Dr. Andrei Pop break down the nuances behind gradient measurements, patient-prosthesis mismatch (PPM), and valve expansion strategy in redo TAVR.

Key takeaways include:

• Why echo gradients differ from invasive gradients even under identical hemodynamics

• Understanding discordance between flow and pressure in post-TAVR assessment

• Why PPM is less concerning in normal-flow patients than previously believed

• How flow state—not gradient—drives outcomes after TAVR or SAVR

• The role of predicted vs measured PPM and valve-specific flow patterns

• Insights on undersizing vs overexpansion and how to optimize redo TAVR results

• Why well-expanded valves may outperform “bigger” but underexpanded ones

• How lifetime management means moving past numbers to patient-centered outcomes

This is a must-watch for interventional cardiologists and structural heart teams focused on redo TAVR planning, flow hemodynamics, and lifetime valve strategies.

00:00 – Introduction: TAVR-in-TAVR and gradient anxiety

01:10 – Invasive vs echo gradients: why they don’t match

03:00 – Discordance and measurement error in post-TAVR gradients

04:25 – Understanding pre-discharge echo gradient increases

05:15 – When gradients are “nuisance” findings vs real issues

06:00 – PPM redefined: what echo really measures

07:30 – Flow-derived valve area and its pitfalls

09:00 – Flow vs gradient: the real driver of outcomes

10:00 – Lessons from the PARTNER and TVT data

12:30 – Predicted vs measured PPM in clinical context

14:00 – The role of ejection fraction and low-flow states

16:00 – Flow patterns: laminar vs turbulent impact on velocity

18:00 – Valve sizing: smaller expanded vs larger underexpanded

20:00 – Expansion optimization and stent analogy

22:00 – Valve labeling, true ID, and expansion limits

24:30 – Historical shift: from “biggest valve possible” to “best expansion possible”

26:30 – Oversizing risks, skirts, and modern generation valves

28:00 – The balance between PVL, pacemaker risk, and expansion

30:00 – Lifetime management: beyond numbers to patient outcomes

31:00 – Closing thoughts & takeaways

#TAVR #ValveInValve #TAVinTAV #InterventionalCardiology #StructuralHeart #Echocardiography #AorticValve #PPM #Hemodynamics #MurmurMD