Effect of Transaortic Valve Intervention for Aortic Stenosis on Myocardial Mechanics

https://doi.org/10.1016/j.amjcard.2021.01.021Get rights and content

HIGHLIGHTS

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    Left ventricular (LV) remodeling occurs after TAVI in this population, regardless of gender; remodeling occurs more significantly in those with a baseline LV ejection fraction of <60%.

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    Afterload, driven by the decrease in transvalvular gradient, decreased significantly in the entire cohort and all 4 subgroups.

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    LV chamber and myocardial function, assessed by left ventricular ejection fraction and mid wall fractional shortening, respectively, remain unchanged or decreased.

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    These data run counter to the paradigm that afterload reduction improves systolic function and suggests that more complicated mechanisms are at work in these patients.

Chronic afterload excess in aortic stenosis results in compensatory concentric hypertrophy which mitigates the increased systolic load. Surgical aortic valve replacement has been shown to decrease afterload and improve left ventricular (LV) ejection fraction (EF). The extent to which these changes take place in patients undergoing TAVI (transcatheter aortic valve intervention) may be different than what has been observed in the surgical aortic valve replacement patients who were generally younger with few co-morbidities. Accordingly, we analyzed indices of LV structure and ventricular mechanics pre- and 1-year after TAVI in 397 patients (mean age 81±9, 46% women) with severe symptomatic aortic stenosis, complete echocardiographic data was available in 156 patients and these patients compromised our study population. Our principal findings are: (1) LV remodeling occurs after TAVI; (2) afterload decreases significantly; (3) LV chamber and myocardial function, assessed by left ventricular ejection fraction and midwall fractional shortening, and stroke volume, respectively, remain unchanged or decrease. In conclusion, TAVI effects LV remodeling despite significant co-morbidities. Thus, TAVI reduces afterload and leads to LV remodeling. Surprisingly, however, systolic function does not improve. These data run counter to the paradigm that afterload reduction improves systolic function and suggest that the response to afterload reduction is complex in the TAVI population.

Section snippets

Methods

This was a single-center, retrospective study of clinical and echocardiographic data of all patients with severe AS prior to and 1-year after TAVI at The Christ Hospital Heart and Vascular Center from May 2011 to April 2017. Patients were included in the analysis if they had an echocardiogram at least one day prior to TAVI and up to 1-year after procedure. Demographic and clinical data of all patients were retrieved. In addition to analyzing data from the entire cohort, we performed 2 subgroup

Results

A total of 397 subjects who underwent TAVI were included in the demographic analysis. We had complete data for 160 patients regarding LV dimensions pre and 1-year after TAVI and complete data for 156 patients regarding LV mass pre and after TAVI. As expected, the population had a significant burden of co-morbidities, see Table 1. TAVI was associated with LV mass regression and remodeling as shown in Table 2. As expected, eSS dropped significantly. SV decreased significantly. There was a trend

Discussion

We undertook this study to evaluate LV remodeling and changes in systolic function after TAVI in an older population with severe AS and multiple cardiac co-morbidities. Secondary aims were to analyze these changes by baseline LVEF and by gender. Since systolic hypertension adds a second load to the LV of patients with AS,8 we used Zva, the sum of the mean pressure gradient across the aortic valve and the systolic pressure divided by the LV stroke volume, indexed to body surface area (BSA) as a

Credit Author Statement

Conception or Design of Work: Colleen Harrington, Matthew Gottbrecht, Eugene Chung and Gerard Aurigemma. Data Collection: Vien Truong; Data Analysis and Collection: Nouran Sorour, Ahmed Nagy, Colleen Harrington, Gerard Aurigemma, Matthew Gottbrecht, Eugene Chung; Drafting the Article: Colleen Harrington, Gerard Aurigemma; Critical Revision of the Article: Colleen Harrington, Lara Kovell, Matthew Gottbrecht, Eugene Chung, Gerard Aurigemma; Final Approval of the version to be published: Colleen

Declaration of Competing Interests

The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study.

Refrerences (30)

  • S Gunther et al.

    Determinants of ventricular function in pressure-overload hypertrophy in man

    Circulation

    (1979)
  • MM Elahi et al.

    One problem two issues! Left ventricular systolic and diastolic dysfunction in aortic stenosis

    Ann Transl Med

    (2014)
  • BR Lindman et al.

    Blood pressure and arterial load after transcatheter aortic valve replacement for aortic stenosis

    Circ Cardiovasc Imaging

    (2017)
  • DH Adams et al.

    Transcatheter aortic-valve replacement with a self-expanding prosthesis

    N Engl J Med

    (2014)
  • MB Leon et al.

    Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery

    N Engl J Med

    (2010)

    • Vien Truong, MD receives salary support from Lindner Research Center and Christ Hospital.

    The corresponding author and all co-authors report no conflicts of interest.

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