Transcatheter aortic valve replacement acutely improves left ventricular mechanical efficiency in severe aortic stenosis: effects of different phenotypes

• Published in: Clinical research in cardiology 2020-07, Vol.109 (7), p.819-831
• Main Authors: Marino, Paolo N., Binda, G., Calzaducca, E., Panizza, A., Ferrari, I., Bellacosa, I., Ambrosio, G.
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Aorta; Aortic stenosis; Aortic valve; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - physiopathology; Aortic Valve Stenosis - surgery; Cardiology; Efficiency; External pressure; Female; Heart valves; Humans; Implantation; Male; Matching; Mechanical efficiency; Medical prognosis; Medicine; Medicine & Public Health; Muscles; Original Paper; Oxygen consumption; Phenotypes; Potential energy; Predictive Value of Tests; Prostheses; Reproducibility of Results; Retrospective Studies; Stenosis; Stroke Volume - physiology; Survival Rate; Transcatheter Aortic Valve Replacement; Treatment Outcome; Ventricle; Ventricular Function, Left - physiology; Ventricular Pressure - physiology
• ISSN: 1861-0684; 1861-0692
• DOI: 10.1007/s00392-019-01570-3

Aim Aortic stenosis is a frequent valvular disease, with transcatheter aortic valve implantation (TAVI) being performed when surgical replacement is at increased risk. However, TAVI-induced effects on myocardial efficiency are unknown. We aimed to investigate changes in LV mechano-energetic pre-/post-TAVI and their prognostic impact. Methods A total of 46 patients (25 males) received transesophageal and simultaneous radial pressure plus transaortic gradient monitoring before/immediately after prosthesis deployment. Efficiency was computed as external work/potential energy, as derived from LV pressure–volume plots; myocardial oxygen consumption (MVO 2 ) was estimated as PWI mod , i.e. a noninvasively validated alternative for MVO 2 estimation. Results TAVI was successful in all patients, peak transaortic gradient decreasing − 40 ± 20 mmHg ( p < 0.001). Efficiency improved post-TAVI (+ 0.6 ± 0.12; p  = 0.004), with a concomitant PWI mod  reduction (− 16 ± 31%; p < 0.001). When contextualized to fixed PWI mod value (5 ml/min/100 g), efficiency significantly affected survival ( p  = 0.029). Over 1026 ± 450-day follow-up, a change in efficiency pre-/post-TAVI ≤ 0.021 (median of the difference) predicted more deaths from any cause (30%) as compared with a change > 0.021 (17%), particularly in those patients with a pre-TAVI mean high-gradient (HG ≥ 40 mmHg) phenotype ( p < 0.05). In particular, HG patients exhibited the lowest efficiency/PWI mod ratio pre-/post-TAVI ( p  = 0.048), relative to the other aortic stenosis patients, suggestive of an unfavourable matching between cardiac function and metabolic demand, which foreshortens some intrinsic damaged muscle condition in these patients. Conclusion LV mechanical efficiency improves immediately post-TAVI, notwithstanding an inhomogeneous mechano-energetic matching among the aortic stenosis patients, which can impact negatively on their long-term prognosis, particularly in those with the HG phenotype. Graphic abstract