Impact of Baseline Left Ventricular Diastolic Dysfunction in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

The prognostic impact of diastolic dysfunction after transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

Diastolic dysfunction (DD) is a long-established marker of disease progression in patients with aortic valve stenosis (AS), indicating valvular myocardial damage. Recently, substantial observational data have emerged demonstrating that worse pre-operative DD assessed using echocardiography is associated with adverse long-term clinical outcomes after transcatheter aortic valve replacement (TAVR).

AIM

To systematically appraise and quantitatively synthesize current evidence on the prognostic impact of echocardiographic severe DD derived by echocardiography before TAVR.

METHODS

A systemic literature review was undertaken in electronic databases to identify studies reporting the predictive value of severe DD in AS subjects undergoing TAVR. A random-effects meta-analysis was conducted to quantify the adjusted and unadjusted hazard ratios (HRs) for all-cause mortality and major adverse cardiovascular events (MACEs) for the presence of severe DD.

RESULTS

Ten studies were deemed eligible for inclusion. Of those, 9 provided appropriate quantitative data for the meta-analysis, encompassing a total of 4,619 patients. The presence of severe DD was associated with increased risk for all-cause mortality (pooled unadjusted HR=2.56 [1.46-4.48]; p<0.01; I2=76 %) and MACEs (pooled unadjusted HR=1.82 [1.29-2.58]; p<0.01; I2=86 %). When adjusted for clinically-relevant parameters, the presence of severe DD retained independent association with all-cause mortality (pooled adjusted HR=2.35 [1.26-4.37]; p<0.01; I2=79 %) and MACEs (pooled adjusted HR= 2.52 [1.72-3.65]; p<0.01; I2=0 %). In subgroup analysis there was no difference on post-TAVR risk between the use of different diastolic function grading scores.

CONCLUSION

Presence of severe DD assessed by echocardiography pre-TAVR is a major determinant of long-term adverse outcomes after the procedure.

Prognostic Impact of Modified H2FPEF Score in Patients Receiving Trans-Catheter Aortic Valve Replacement

BACKGROUND

H2FPEF is a recently introduced score for the diagnosis of heart failure with preserved ejection fraction (HFpEF). Many patients with severe aortic stenosis have clinical/subclinical HFpEF and have worsening heart failure even after trans-catheter aortic valve replacement (TAVR). We investigated the prognostic impact of the H2FPEF score in TAVR candidates.

METHODS

Patients undergoing TAVR procedures at a single academic center between 2015 and 2022 were included. The H2FPEF score was calculated using baseline characteristics before TAVR. The prognostic impact of the score on the post-TAVR composite endpoint, consisting of all-cause death and heart failure readmissions during the 2-year observation period, was evaluated.

RESULTS

A total of 244 patients (median age 86 years, 70 males) were included. The median value of H2FPEF score was 3 (2, 4). The score was significantly associated with the primary outcome with a hazard ratio of 1.33 (95% confidence interval 1.02-1.74, p = 0.036). We constructed a modified H2FPEF score by adjusting cutoffs of several items for better prognostic stratification (i.e., age and body mass index). A modified score had a higher area under the curve than the original one (0.65 vs. 0.59, p = 0.028) and was independently associated with the primary outcome with an adjusted hazard ratio of 1.22 (95% confidence interval 1.01-1.49, p = 0.047).

CONCLUSIONS

A modified H2FPEF score, which was originally developed to diagnose the presence of HFpEF, could be used to risk-stratify elderly patients receiving TAVR. The clinical utility of this score should be validated in future studies.

Diastolic versus Systolic Left Ventricular Dysfunction as Independent Predictors for Unfavorable Postoperative Evolution in Patients with Aortic Regurgitation Undergoing Aortic Valve Replacement

Background and Objectives: Chronic severe aortic valve disease is associated with important changes in left ventricle (LV) performance associated with eccentric or concentric LV hypertrophy. We aimed to assess the immediate prognostic implications of the type of the LV diastolic filling pattern (LVDFP) compared with LV systolic performance in patients with severe aortic regurgitation (AR) undergoing aortic valve replacement (AVR) and to define the independent echographic predictors for the immediate and long-term prognoses. Materials and Methods: We performed a prospective study enrolling 332 AR patients undergoing AVR, divided into two groups: Group A—201 pts with normal LV systolic function, divided into two subgroups (A1: 129 pts with a nonrestrictive LVDFP and A2: 72 pts with restrictive LVDFP), and Group B—131 pts with LV systolic dysfunction (LV ejection fraction LVEF < 50%), divided into two subgroups (B1: 83 pts with a nonrestrictive LVDFP and B2: 48 pts with restrictive LVDFP). Results: The early postoperative mortality rate was higher in patients with a restrictive LVDFP (11.12% in A2 and 12.5% in B2) compared with normal LV filling (2.32% in A1 and 7.63% in B1, p < 0.0001), regardless of the LVEF. The restrictive LVDFP—defined by at least one of the following echographic parameters: an E/A > 2 with an E wave deceleration time (EDt) < 100 ms; an isovolumetric relaxation time (IVRT) < 60 ms; or an S/D ratio < 1 in the pulmonary vein flow—was an independent predictor for early postoperative mortality, increasing the relative risk by 8.2-fold. Other independent factors associated with early poor prognosis were an LV end-systolic diameter (LVESD) > 58 mm, an age > 75 years, and the presence of comorbidities (chronic obstructive pulmonary disease-COPD or diabetes mellitus). On a medium-term, an unfavorable evolution was associated with: an age > 75 years (RR = 8.1), an LV end-systolic volume (LVESV) > 95 cm3 (RR = 6.7), a restrictive LVDFP (RR = 9.8, p < 0.0002), and pulmonary hypertension (RR = 8.2). Conclusions: The presence of a restrictive LVDFP in patients with AR undergoing AVR is associated with both increased early and medium-term mortality rates. The LV diastolic function is a more reliable parameter for prognosis than LV systolic performance (RR 9.2 versus 2.1). Other independent predictors for increased early postoperative mortality rate were: an age > 75 years, an LVESD > 58 mm, and comorbidities (diabetes mellitus, COPD), and for unfavorable evolution at 2 years postoperatively: an age > 75 years, an LVESV > 95 cm3, and severe pulmonary hypertension.

Prognostic value of the H2 FPEF score in patients undergoing transcatheter aortic valve implantation

Aims

The aim of this study was to assess the prognostic value of the H₂FPEF score in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) and preserved left ventricular ejection fraction (EF).

Methods and results

In this multicentre study, a total of 832 patients from two German high‐volume centres, who received TAVI for severe AS and preserved EF (≥50%), were identified for calculation of the H₂FPEF score. Patients were dichotomized according to low (0–5 points; n = 570) and high (6–9 points; n = 262) H₂FPEF scores. Kaplan–Meier and Cox regression analyses were applied to assess the prognostic impact of the H₂FPEF score. We observed a decrease in stroke volume index (−2.04 mL/m²/point) and mean transvalvular gradients (−1.14 mmHg/point) with increasing H₂FPEF score translating into a higher prevalence of paradoxical low‐flow, low‐gradient AS among patients with high H₂FPEF score. One year after TAVI, the rates of all‐cause (low vs. high H₂FPEF score: 8.0% vs. 19.4%, P < 0.0001) and cardiovascular (CV) mortality (1.9% vs. 9.0%, P < 0.0001) as well as the rate of CV mortality or rehospitalization for congestive heart failure (6.4% vs. 23.2%, P < 0.0001) were higher in patients with high H₂FPEF score compared with those with low H₂FPEF score. After multivariable analysis, a high H₂FPEF score remained independently predictive of all‐cause mortality [hazard ratio 1.59 (1.28–2.35), P = 0.018] and CV mortality or rehospitalization for congestive heart failure [hazard ratio 2.92 (1.65–5.15), P < 0.001]. Among the H₂FPEF score variables, atrial fibrillation, pulmonary hypertension, and elevated left ventricular filling pressure were the strongest outcome predictors.

Conclusions

The H₂FPEF score serves as an independent predictor of adverse CV and heart failure outcome among TAVI patients with preserved EF. A high H₂FPEF score is associated with the presence of paradoxical low‐flow, low‐gradient AS, the HFpEF in patients with AS. By identifying patients in advanced stages of HFpEF, the H₂FPEF score might be useful as a risk prediction tool in patients with preserved EF scheduled for TAVI.