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Effect of Transaortic Valve Intervention for Aortic Stenosis on Myocardial Mechanics

Published:January 30, 2021DOI:https://doi.org/10.1016/j.amjcard.2021.01.021

      HIGHLIGHTS

      • 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%.
      • Afterload, driven by the decrease in transvalvular gradient, decreased significantly in the entire cohort and all 4 subgroups.
      • LV chamber and myocardial function, assessed by left ventricular ejection fraction and mid wall fractional shortening, respectively, remain unchanged or decreased.
      • 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.
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