Systemic Vascular Load in Calcific Degenerative Aortic Valve Stenosis

Prognostic value of brachial-ankle pulse wave velocity changes post-transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) offers a solution, especially for high-risk aortic stenosis (AS) patients. However, patient outcomes post-TAVR show variability, highlighting the need for reliable prognostic indicators. Brachial-ankle pulse wave velocity (baPWV), a measure of arterial stiffness, may predict outcomes post-TAVR. This study aims to explore baPWV's prognostic value in relation to all-cause mortality post-TAVR. This study prospectively enrolled 212 severe AS patients undergoing TAVR between September 2015 and December 2021, focusing on pre- and post-TAVR baPWV measurements to explore associations with all-cause mortality. Of the 212 patients (119 females, 93 males, mean age 85 years), post-TAVR baPWV increased significantly from 1589 ± 376 to 2010 ± 521 cm/s (p < 0.001). Aortic valve (AV) peak velocity and mean pressure gradient decreased, while AV area increased, indicating procedural success. Despite this, 88% of patients experienced an increase in baPWV, with higher pre-procedure AV peak velocity and mean pressure gradient identified as predictors of increased baPWV post-TAVR. Over 23 months, 29 patients (14%) reached the primary endpoint of all-cause mortality. Notably, changes in baPWV, rather than baseline values, were significantly associated with event-free survival (HR: 0.64 per 1SD increase, p = 0.009). The study highlights the prognostic value of baPWV changes post-TAVR in predicting patient outcomes. Elevated baPWV post-TAVR may reflect a beneficial adaptation to altered hemodynamics, suggesting the need for individualized patient evaluation and the integration of baPWV measurements into clinical practice for improved post-TAVR management.

The Effect of Surgical Aortic Valve Replacement on Arterial Stiffness: Does the Valve Type Matter?

Background: Despite the increasing use of transcatheter aortic valve procedures, many patients still require surgical aortic valve replacement (SAVR). Assessing arterial properties in patients undergoing SAVR for aortic valve stenosis can be challenging, and the existing evidence is inconclusive. Our study aimed to investigate the impact of SAVR on vascular stiffness and the quality of life, as well as the different effects of valve type on arterial properties. Methods: We included 60 patients (mean age 70.25 ± 8.76 years, 65% men) with severe symptomatic aortic stenosis who underwent SAVR. Arterial stiffness (cfPWV, baPWV) and vascular parameters (AIx@75, central pressures, SEVR) were measured at baseline, pre-discharge, and 1-year post-operation. The QOL was assessed using the generic questionnaire-short-form health survey 36 (SF-36) pre-operatively and at 1 year. Results: Post-SAVR, cfPWV increased immediately (7.67 ± 1.70 m/s vs. 8.27 ± 1.92 m/s, p = 0.009) and persisted at 1 year (8.27 ± 1.92 m/s vs. 9.29 ± 2.59 m/s, p ≤ 0.001). Similarly, baPWV (n = 55) increased acutely (1633 ± 429 cm/s vs. 2014 ± 606 cm/s, p < 0.001) and remained elevated at 1 year (1633 ± 429 cm/s vs. 1867 ± 408 cm/s, p < 0.001). Acute decrease in Alx@75 (31.16 ± 10% vs. 22.48 ± 13%, p < 0.001) reversed at 1 year (31.16 ± 10% vs. 30.98 ± 9%, p = 0.71). SEVR improved (136.1 ± 30.4% vs. 149.2 ± 32.7%, p = 0.01) and persisted at 1 year (136.1 ± 30.4% vs. 147.5 ± 30.4%, p = 0.01). SV had a greater cfPWV increase at 1 year (p = 0.049). The QOL improved irrespective of arterial stiffness changes. Conclusions: After SAVR, arterial stiffness demonstrates a persistent increase at 1-year, with valve type having a slight influence on the outcomes. These findings remain consistent despite the perceived QOL.

Specific Multiomic Profiling in Aortic Stenosis in Bicuspid Aortic Valve Disease

INTRODUCTION AND PURPOSE

Bicuspid aortic valve (BAV) disease is associated with faster aortic valve degeneration and a high incidence of aortic stenosis (AS). In this study, we aimed to identify differences in the pathophysiology of AS between BAV and tricuspid aortic valve (TAV) patients in a multiomics study integrating metabolomics and transcriptomics as well as clinical data.

METHODS

Eighteen patients underwent aortic valve replacement due to severe aortic stenosis: 8 of them had a TAV, while 10 of them had a BAV. RNA sequencing (RNA-seq) and proton nuclear magnetic resonance spectroscopy (1H-NMR) were performed on these tissue samples to obtain the RNA profile and lipid and low-molecular-weight metabolites. These results combined with clinical data were posteriorly compared, and a multiomic profile specific to AS in BAV disease was obtained.

RESULTS

H-NMR results showed that BAV patients with AS had different metabolic profiles than TAV patients. RNA-seq also showed differential RNA expression between the groups. Functional analysis helped connect this RNA pattern to mitochondrial dysfunction. Integration of RNA-seq, 1H-NMR and clinical data helped create a multiomic profile that suggested that mitochondrial dysfunction and oxidative stress are key players in the pathophysiology of AS in BAV disease.

CONCLUSIONS

The pathophysiology of AS in BAV disease differs from patients with a TAV and has a specific RNA and metabolic profile. This profile was associated with mitochondrial dysfunction and increased oxidative stress.

Accuracy of Transcutaneous Carbon Dioxide Measurement During Transcatheter Aortic Valve Replacement Under Monitored Anesthesia Care: A Prospective Observational Study

Background Transcutaneous carbon dioxide tension (PtcCO2) measurement is a promising alternative to arterial carbon dioxide tension (PaCO2) measurement. PaCO2 measurement is invasive and intermittent, whereas PtcCO2 measurement is non-invasive and continuous. However, previous studies evaluating PtcCO2measurements did not include patients undergoing transcatheter aortic valve replacement (TAVR), who experience anticipated hemodynamic changes, particularly before and after valve placement. Therefore, we investigated whether PtcCO2 measurement could provide an alternative to PaCO2 measurement during transfemoral TAVR under monitored anesthesia care (MAC) with local anesthesia. Methodology We conducted a prospective observational study. We included all consecutive patients with severe aortic stenosis who were scheduled to undergo a transfemoral TAVR under MAC at our institution from November 1, 2020, to April 30, 2021. During the procedures, PaCO2 and PtcCO2 were concurrently monitored six times as a reference standard and index test, respectively. PtcCO2 was monitored continuously using a non-invasive earlobe sensor. The agreement between PtcCO2 and PaCO2 measurements was assessed using the Bland-Altman method, and the 95% limits of agreement were calculated. Based on previous studies, we determined that 95% limits of agreement of ±6.0 mmHg would be clinically acceptable to define PtcCO2 as an alternative to PaCO2. Results We obtained 88 measurement pairs from 15 patients. The lower and upper 95% limits of agreement between the PtcCO2 and PaCO2 measurements were -4.22 mmHg and 6.56 mmHg, respectively. Conclusions During TAVR under MAC with local anesthesia, PtcCO2 measurement could not provide a viable alternative to PaCO2 measurement to reduce high PaCO2 events. This study focused on comparing intraoperative periods before and after valve implantation. Therefore, further investigation is warranted to assess the impact of various factors, including the prosthetic valve type and the hemodynamic effects of balloon aortic valvuloplasty, on PtcCO2 measurement in TAVR.

Positive blood pressure response may predict the recovery of renal function after transcatheter aortic valve implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) may ameliorate renal function and increase blood pressure (BP). We aimed to investigate the association between increased BP and improved renal function (IRF) after TAVI.

METHODS

A total of 176 patients who had undergone TAVI were evaluated retrospectively. BP records that were taken 24 h before and 72 h after TAVI were reviewed. Pre-procedural, post-procedural 48 h, and the first month estimated glomerular filtration rate (eGFR) levels were noted. IRF was accepted as a ≥ 10% increase in eGFR. The predictors of acute kidney injury (AKI) development at 48 h and IRF at 1 month were investigated. The association between mortality and BP response was assessed.

RESULTS

A total of 157 patients were included in this study after exclusion as defined in the methodology. Mean age was 78.1 ± 7,1 and 51.6% were female. AKI occurred in 25.5% of patients and baseline eGFR and male gender were found as independent predictors for AKI development. IRF was observed in 16% at 48 h and 31.8% of patients at 1-month follow-up. Positive BP response was seen in 42% of patients. Pre-procedural chronic kidney disease, positive BP response, and an early increase in eGFR emerged as independent predictors of IRF at the first month. The patients with positive BP response were found to have decreased mortality at 710 days follow-up.

CONCLUSION

Positive BP response after TAVI is related to improved survival and renal functions. The beneficial effect of TAVI on renal function may be precisely evaluated at 1st month rather than 48 h.

Differential Impact of Blood Pressure Control Targets on Epicardial Coronary Flow After Transcatheter Aortic Valve Replacement

Background

The cause for the association between increased cardiovascular mortality rates and lower blood pressure (BP) after aortic valve replacement (AVR) is unclear. This study aims to assess how the epicardial coronary flow (ECF) after AVR varies as BP levels are changed in the presence of a right coronary lesion.

Methods

The hemodynamics of a 3D printed aortic root model with a SAPIEN 3 26 deployed were evaluated in an in vitro left heart simulator under a range of varying systolic blood pressure (SBP) and diastolic blood pressure (DBP). ECF and the flow ratio index were calculated. Flow index value <0.8 was considered a threshold for ischemia.

Results

As SBP decreased, the average ECF decreased below the physiological coronary minimum at 120 mmHg. As DBP decreased, the average ECF was still maintained above the physiological minimum. The flow ratio index was >0.9 for SBP ≥130 mmHg. However, at an SBP of 120 mmHg, the flow ratio was 0.63 (p ≤ 0.0055). With decreasing DBP, no BP condition yielded a flow ratio index that was less than 0.91.

Conclusions

Reducing BP to the current recommended levels assigned for the general population after AVR in the presence of coronary artery disease may require reconsideration of levels and treatment priority. Additional studies are needed to fully understand the changes in ECF dynamics after AVR in the presence and absence of coronary artery disease.

A novel interpretative tool for early prediction of low cardiac output syndrome after valve surgery: online machine learning models

OBJECTIVE

Low cardiac output syndrome (LCOS) is a severe complication after valve surgery, with no uniform standard for early identification. We developed interpretative machine learning (ML) models for predicting LCOS risk preoperatively and 0.5 h postoperatively for intervention in advance.

METHODS

A total of 2218 patients undergoing valve surgery from June 2019 to Dec 2021 were finally enrolled to construct preoperative and postoperative models. Logistic regression, support vector machine (SVM), random forest classifier, extreme gradient boosting, and deep neural network were executed for model construction, and the performance of models was evaluated by area under the curve (AUC) of the receiver operating characteristic and calibration curves. Our models were interpreted through SHapley Additive exPlanations, and presented as an online tool to improve clinical operability.

RESULTS

The SVM algorithm was chosen for modeling due to better AUC and calibration capability. The AUCs of the preoperative and postoperative models were 0.786 (95% CI 0.729-0.843) and 0.863 (95% CI 0.824-0.902), and the Brier scores were 0.123 and 0.107. Our models have higher timeliness and interpretability, and wider coverage than the vasoactive-inotropic score, and the AUC of the postoperative model was significantly higher. Our preoperative and postoperative models are available online at http://njfh-yxb.com.cn:2022/lcos.

CONCLUSIONS

The first interpretable ML tool with two prediction periods for online early prediction of LCOS risk after valve surgery was successfully built in this study, in which the SVM model has the best performance, reserving enough time for early precise intervention in critical care.

Increased Chamber Resting Tone Is a Key Determinant of Left Ventricular Diastolic Dysfunction

BACKGROUND

Twitch-independent tension has been demonstrated in cardiomyocytes, but its role in heart failure (HF) is unclear. We aimed to address twitch-independent tension as a source of diastolic dysfunction by isolating the effects of chamber resting tone (RT) from impaired relaxation and stiffness.

METHODS

We invasively monitored pressure-volume data during cardiopulmonary exercise in 20 patients with hypertrophic cardiomyopathy, 17 control subjects, and 35 patients with HF with preserved ejection fraction. To measure RT, we developed a new method to fit continuous pressure-volume measurements, and first validated it in a computational model of loss of cMyBP-C (myosin binding protein-C).

RESULTS

In hypertrophic cardiomyopathy, RT (estimated marginal mean [95% CI]) was 3.4 (0.4-6.4) mm Hg, increasing to 18.5 (15.5-21.5) mm Hg with exercise (P<0.001). At peak exercise, RT was responsible for 64% (53%-76%) of end-diastolic pressure, whereas incomplete relaxation and stiffness accounted for the rest. RT correlated with the levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide; R=0.57; P=0.02) and with pulmonary wedge pressure but following different slopes at rest and during exercise (R2=0.49; P<0.001). In controls, RT was 0.0 mm Hg and 1.2 (0.3-2.8) mm Hg in HF with preserved ejection fraction patients and was also exacerbated by exercise. In silico, RT increased in parallel to the loss of cMyBP-C function and correlated with twitch-independent myofilament tension (R=0.997).

CONCLUSIONS

Augmented RT is the major cause of LV diastolic chamber dysfunction in hypertrophic cardiomyopathy and HF with preserved ejection fraction. RT transients determine diastolic pressures, pulmonary pressures, and functional capacity to a greater extent than relaxation and stiffness abnormalities. These findings support antimyosin agents for treating HF.

First description and validation of a new method for estimating aortic stenosis burden and predicting the functional response to TAVI

Background

Up to one-fifth of patients continue to have poor quality of life after transcatheter aortic valve implantation (TAVI), with an additional similar proportion not surviving 1 year after the procedure. We aimed to assess the value of a new method based on an integrated analysis of left ventricular outflow tract flow velocity and aortic pressure to predict objective functional improvement and prognosis after TAVI.

Methods

In a cohort of consecutive patients undergoing TAVI, flow velocity-pressure integrated analysis was obtained from simultaneous pressure recordings in the ascending aorta and flow velocity recordings in the left ventricular outflow tract by echocardiography. Objective functional improvement 6 months after TAVI was assessed through changes in a 6-min walk test and NT-proBNP levels. A clinical follow-up was conducted at 2 years.

Results

Of the 102 patients studied, 82 (80.4%) showed objective functional improvement. The 2-year mortality of these patients was significantly lower (9% vs. 44%, p = 0.001). In multivariate analysis, parameter "(Pressure at Vmax - Pressure at Vo)/Vmax" was found to be an independent predictor for objective improvement. The C-statistic was 0.70 in the overall population and 0.78 in the low-gradient subgroup. All echocardiographic parameters and the valvuloarterial impedance showed a C-statistic of <0.6 for the overall and low-gradient patients. In a validation cohort of 119 patients, the C-statistic was 0.67 for the total cohort and 0.76 for the low-gradient subgroup.

Conclusion

This new method allows predicting objective functional improvement after TAVI more precisely than the conventional parameters used to assess the severity of aortic stenosis, particularly in low-gradient patients.

Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study

INTRODUCTION AND OBJECTIVES

Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data.

METHODS

This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery.

RESULTS

OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017).

CONCLUSIONS

Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.

Noninvasive Hemodynamic Evaluation Following TAVI for Severe Aortic Stenosis

Background Various hemodynamic changes occur following transcatheter aortic valve implantation (TAVI) that may impact therapeutic decisions. NICaS is a noninvasive bioimpedance monitoring system aimed at hemodynamic assessment. We used the NICaS system in patients with severe aortic stenosis (AS) to evaluate short-term hemodynamic changes after TAVI. Methods and Results We performed hemodynamic analysis using NICaS on 97 patients with severe AS who underwent TAVI using either self-expandable (68%) or balloon-expandable (32%) valves. Patients were more often women (54%) and had multiple comorbidities including hypertension (83%), coronary artery disease (46%), and diabetes (37%). NICaS was performed at several time points-before TAVI, soon after TAVI, at hospital discharge, and during follow-up. Compared with baseline NICaS measurements, we observed a significant increase in systolic blood pressure and total peripheral resistance (systolic blood pressure 132±21 mm Hg at baseline versus 147±23 mm Hg after TAVI, P<0.001; total peripheral resistance 1751±512 versus 2084±762 dynes*s/cm⁵, respectively, P<0.001) concurrent with a decrease in cardiac output and stroke volume (cardiac output 4.2±1.5 versus 3.9±1.3 L/min, P=0.037; stroke volume 61.4±14.8 versus 56.2±15.9 mL, P=0.001) in the immediate post-TAVI period. At follow-up (median 59 days [interquartile range, 40.5-91]) these measurements returned to values that were not different from the baseline. A significant improvement in echocardiography-based left ventricular ejection fraction was observed from baseline to follow-up (55.6%±11.6% to 59.4%±9.4%, P<0.001). Conclusions Unique short-term adaptive hemodynamic changes were observed using NICaS in patients with AS soon after TAVI. Noninvasive hemodynamic evaluation immediately following TAVI may contribute to the understanding of complex hemodynamic changes and merits favorable consideration.

Pulsatile energy consumption as a surrogate marker for vascular afterload improves with time post transcatheter aortic valve replacement in patients with aortic stenosis

The effect of arterial stiffening on elevated pulsatile left ventricular afterload patients with aortic stenosis (AS) is pronounced beyond systemic hypertension. Circulatory afterload pulsatile efficiency (CAPE) is a marker of vascular function, defined as the ratio of steady state energy consumption (SEC) to maintain systemic circulation and pulsatile energy consumption (PEC). Twenty patients aged 80 ± 7 years were assessed at baseline and a median of 60 days post transcatheter aortic valve replacement (TAVR), with pulsatile vascular load calculated using simultaneous radial applanation tonometry derived aortic pressure and cardiac magnetic resonance phase-contrast imaging derived ascending aortic flow. Eight out of 20 patients had a reduction in PEC post TAVR, and the reduction of PEC correlated strongly with the number of days post TAVR (R = 0.62, P < 0.01). Patients assessed within the 100 days of TAVR had a rise in their PEC when compared to baseline (0.19 ± 0.09 vs 0.14 ± 0.08 W, P = 0.04). Baseline PEC correlated moderately with baseline SEC (R = 0.49, P = 0.03), and a high baseline PEC was predictive of post TAVR PEC reduction (R = 0.54, P =0.01). Overall, no significant differences were found between baseline and post TAVR for systolic aortic pressure (131 ± 20 vs 131 ± 20 mmHg), systemic vascular resistance (1894 ± 493 vs 2015 ± 519 dynes.s/cm⁵), aortic valve ejection time (337 ± 22 vs 324 ± 34 ms) or aortic characteristic impedance (120 ± 48 vs 107 ± 41 dynes.s/cm⁵). Improved flow profiles after TAVR likely unmask the true vascular properties by altering ventriculo-valvulo-arterial coupling, leading to downstream vascular remodelling secondary to flow conditioning, and results in eventual improvement of pulsatile afterload as reflected by our proposed index of CAPE.

A new integrative approach to assess aortic stenosis burden and predict objective functional improvement after TAVR

Background

A non-negligible rate of patients undergoing transcatheter aortic valve replacement (TAVR) do not report symptomatic improvement or even die in the short-midterm. We sought to assess the degree of objective functional recovery after TAVR and its prognostic implications and to develop a predictive model.

Methods

In a cohort of patients undergoing TAVR, a prospective evaluation of clinical, anatomical, and physiological parameters was conducted before and after the procedure. These parameters were derived from echocardiography, non-invasive analysis of arterial pulse waves, and cardiac tomography. Objective functional improvement 6 months after TAVR was assessed using a 6-min walk test and nitro-terminal pro-brain natriuretic peptide (NT-proBNP) levels. The derived predictive model was prospectively validated in a different cohort. A clinical follow-up was conducted at 2 years.

Results

Among the 212 patients included, objective functional improvement was observed in 169 patients (80%) and subjective improvement in 187 (88%). Patients with objective functional improvement showed a much lower death rate at 2 years (9% vs. 31% p = 0.0002). Independent predictors of improvement were as follows: mean aortic gradient of ≥40 mmHg, augmentation index₇₅ of ≥45%, the posterior wall thickness of ≤12 mm, and absence of atrial fibrillation. A simple integer-based point score was developed (GAPA score), which showed an area under the curve of 0.81 for the overall cohort and 0.78 for the low-gradient subgroup. In a validation cohort of 216 patients, these values were 0.75 and 0.76, respectively.

Conclusion

A total of 80% of patients experienced objective functional improvement after TAVR, showing a significantly lower 2-year mortality rate. A predictive score was built that showed a good discriminative performance in overall and low-gradient populations.

Pulmonary Vascular Remodeling and Prognosis in Patients Evaluated for Heart Transplantation: Insights from the OCTOPUS-CHF Study

OBJECTIVE

In patients with advanced heart failure, the intravascular optical coherence tomography (OCT) of subsegmental pulmonary artery measurements is correlated with right heart catheterization parameters. Our aim was to study the prognostic value of pulmonary OCT, right heart catheterization data, and the echocardiographic estimation of pulmonary pressure in patients studied for elective heart transplants.

METHODS

This research is an observational, prospective, multicenter study involving 90 adults with a one-year follow-up.

RESULTS

A total of 10 patients (11.1%) died due to worsening heart failure before heart transplantation, 50 underwent a heart transplant (55.6%), and 9 died in the first year after the transplant. The patients with and without events (mortality or heart failure-induced hospitalization) had similar data regarding echocardiography, right heart catheterization, and pulmonary OCT (with a median estimated pulmonary artery systolic pressure of 42.0 mmHg, interquartile range (IQR) of 30.3-50.0 vs. 47.0 mmHg, IQR 34.6-59.5 and p = 0.79, median pulmonary vascular resistance of 2.2 Wood units, IQR 1.3-3.7 vs. 2.0 Wood units, IQR 1.4-3.2 and p = 0.99, and a median pulmonary artery wall thickness of 0.2 ± 0.5 mm vs. 0.2 ± 0.6 mm and p = 0.87).

CONCLUSION

Pulmonary vascular remodeling (evaluated with echocardiography, right heart catheterization, and pulmonary OCT) was not associated with prognosis in a selected sample of adults evaluated for elective heart transplants. Pulmonary OCT is safe and feasible for the evaluation of these patients.

Arterial stiffness in aortic stenosis - complex clinical and prognostic implications

Arterial stiffness and degenerative aortic stenosis (AoS) are frequently associated leading to a combined valvular and vascular load imposed on the left ventricle (LV). Vascular load consists of a pulsatile load represented by arterial stiffness and a steady load corresponding to vascular resistance. Increased vascular load in AoS has been associated with LV dysfunction and poor prognosis in pre-intervention state, as well as after aortic valve replacement (AVR), suggesting that the evaluation of arterial load in AoS may have clinical benefits. Nevertheless, studies that investigated arterial stiffness in AoS either before or after AVR used various methods of measurement and their results are conflicting. The aim of the present review was to summarize the main pathophysiological mechanisms which may explain the complex valvulo-arterial interplay in AoS and their consequences on LV structure and function on the patients' outcome. Future larger studies are needed to clarify the complex hemodynamic modifications produced by increased vascular load in AoS and its changes after AVR. Prospective evaluation is needed to confirm the prognostic value of arterial stiffness in patients with AoS. Simple, non-invasive, reliable methods which must be validated in AoS still remain to be established before implementing arterial stiffness measurement in patients with AoS in clinical practice.

Improvement of hemodynamic parameters in aortic stenosis patients with transcatheter valve replacement by using impedance cardiography

Background

The hemodynamic changes of patients with aortic stenosis (AS) who underwent transcatheter valve replacement (TAVR) have not been completely investigated.

Methods and results

We enrolled 74 patients with AS who underwent TAVR and assessed cardiac function changes at 1 week post-operation by impedance cardiography (ICG) in a supine position at rest for more than 15 min. Of the 74 patients, 47 had preserved left ventricular ejection fraction (LVEF ≥ 50%; preserved-LVEF group) and 27 had reduced LVEF (LVEF <50%; reduced-LVEF group). TAVR improved the cardiac structure and function, as evidenced by the decrease in the left ventricular end-diastolic (LVED), left atrial diameter (LAD), and an increase in the LVEF. We observed a decrease in N-terminal pro-brain natriuretic peptide (NT-proBNP) level compared to that before treatment. Moreover, patients with reduced LVEF had a more significant reduction of NT-proBNP than those with preserved LVEF. Meanwhile, the blood pressure of patients had no significant differences pre- and post-operation. Based on ICG, there were no changes in the parameter of cardiac preload [thoracic fluid content (TFC)]. We observed an improvement in parameters of diastolic cardiac function [left ventricular ejection time (LVET) and pre-ejection period (PEP)]. And we detected converse results in parameters of heart systolic function [systolic time ratio (STR), cardiac output (CO), cardiac index (CI), stroke index (SI), and stroke volume (SV)] and cardiac afterload [stroke systemic vascular resistance (SSVR) and SSVR-index (SSVRI)]. In addition, TFC level was decreased in patients with thoracic volume overload after valve replacement. Subgroup analysis showed that the changes in those parameters were more noticeable in patients with reduced LVEF than that with preserved LVEF. Moreover, we observed no effects on parameters of heart systolic function and heart afterload in the LVEF ≥ 50% group before and after TAVR.

Conclusion

Our data revealed a beneficial effect of TAVR in diastolic function and preload as detected by the ICG. But the LV systolic function and cardiac afterload were not improved in patients with LVEF <50%. The result indicated that ICG could be used as an important technique to monitor the cardiac condition of patients after aortic valve replacement.

New Evidence About Aortic Valve Stenosis and Cardiovascular Hemodynamics

Aortic stenosis (AS) is the most common degenerative valvular disease in western word. In patients with severe AS, small changes in aortic valve area can lead to large changes in hemodynamics. The correct understanding of cardiac hemodynamics and its interaction with vascular function is of paramount importance for correct identification of severe AS and to plan effective strategies for its treatment. In the current review with highlight the importance of pressure recovery phenomenon and valvular arterial impedance as novel tools in the evaluation of patients with aortic stenosis.

Arterial Stiffness in Aortic Stenosis and the Impact of Aortic Valve Replacement

The most common cause for interventional valve treatment is aortic stenosis. A cardinal symptom of aortic stenosis is heart failure due to the increased load exerted on the left ventricle. However, the left ventricular load is not solely determined based on the degree of aortic stenosis but is also impacted by arterial stiffness. The combined load can be determined by valvulo-arterial impedance (Zva), which is associated with poor outcome in aortic stenosis. We recently demonstrated low measures of systemic arterial stiffness in patients with aortic stenosis, and that arterial stiffness was increased after surgical aortic valve replacement. The results indicated a masked arterial stiffness in aortic stenosis when using methods incorporating peripheral arterial segments. Available studies using several different methods to assess arterial stiffness in relatively small aortic stenosis cohorts examined before and after either surgical or transcatheter aortic valve replacement/intervention have generated contradictory results. In this commentary, we present a detailed literature review to explore how different methods and measures of arterial stiffness in aortic stenosis capture or not, a masked arterial stiffness in aortic stenosis and possible reasons for the observed results. Future studies validating a non-invasive reproducible method to assess arterial stiffness in aortic stenosis patients could potentially lead to an implementation in pre-interventional risk assessment for aortic stenosis.

Cardiovascular Risk Factors and Hemodynamic Measures as Determinants of Increased Arterial Stiffness Following Surgical Aortic Valve Replacement

Valvular and arterial function are tightly intertwined, both in terms of structural changes and hemodynamics. While proximal valvulo-vascular coupling contributes to the cardiovascular consequences of aortic stenosis, less is known on how peripheral arterial stiffness relates to aortic valve disease. Previous studies have shown conflicting results regarding the impact of aortic valve replacement on arterial stiffness. The aim of the present study was therefore to determine predictors of arterial stiffness in patients with and without aortic valve disease undergoing cardiac surgery. Cardio ankle vascular index (CAVI) and carotid femoral pulse wave velocity (cfPWV) were measured to determine arterial stiffness the day before and 3 days after surgery for either ascending aortic or aortic valve disease. Stratification on indication for surgery revealed that CAVI was significantly lower in patients with aortic valve stenosis (n = 45) and aortic valve regurgitation (n=30) compared with those with isolated ascending aortic dilatation (n = 13). After surgery, a significant increased CAVI was observed in aortic stenosis (median 1.34, IQR 0.74-2.26, p < 0.001) and regurgitation (median 1.04, IQR 0.01-1.49, p = 0.003) patients while cfPWV was not significantly changed. Age, diabetes, low body mass index, low pre-operative CAVI, as well as changes in ejection time were independently associated with increased CAVI after surgery. The results of the present study suggest aortic valve disease as cause of underestimation of arterial stiffness when including peripheral segments. We report cardiovascular risk factors and pinpoint the hemodynamic aspect ejection time to be associated with increased CAVI after aortic valve surgery.

Ageing, Hypertension and Aortic Valve Stenosis: A Conscious Uncoupling

Aortic valve stenosis (AS) is no longer considered to be a disease of fixed left ventricular (LV) afterload (due to an obstructive valve), but rather, functions as a series circuit with important contributions from both the valve and ageing vasculature. Patients with AS are frequently elderly, with hypertension and a markedly remodelled aorta. The arterial component is sizable, and yet, the contribution of ventricular afterload has been difficult to determine. Arterial stiffening increases the speed of propagation of the blood pressure wave along the central arteries (estimated as the pulse wave velocity), which results in an earlier return of reflected waves. The effect is to augment blood pressure in the proximal aorta during systole, increasing the central pulse pressure and, in turn, placing even greater afterload on the heart. Elevated global LV afterload is known to have adverse consequences on LV remodelling, function and survival in patients with AS. Consequently, there is renewed focus on methods to estimate the relative contributions of local versus global changes in arterial mechanics and valvular haemodynamics in patients with AS. We present a review on existing and upcoming methods to quantify valvulo-arterial impedance and thereby global LV load in patients with AS.

Arterial biomarkers in the evaluation, management and prognosis of aortic stenosis

Degenerative aortic valve stenosis is the most common primary valve disease and a significant cause of cardiovascular morbidity and mortality. In an era when new techniques for the management of aortic stenosis are gaining ground, the understanding of this disease is more important than ever to optimize treatment. So far, the focus has been placed on the assessment of the valve itself. However, the role that the arterial system plays in the pathogenesis and natural history of the disease needs to be further elucidated. Arteriosclerosis, when it coexists with a stenotic valve, augments the load posed on the left ventricle contributing to greater impairment of cardiovascular function. Arterial stiffness, a well-established predictor for cardiovascular disease and all-cause mortality, could play a role in the prognosis and quality of life of this population. Several studies using a variety of indices to assess arterial stiffness have tried to address the potential utility of arterial function assessment in the case of aortic stenosis. Importantly, reliable data identify a prognostic role of arterial biomarkers in aortic stenosis and stress their possible use to optimize timing and method of treatment. This review aims at summarizing the existing knowledge on the interplay between the heart and the vessels in the presence of degenerative aortic stenosis, prior, upon and after interventional management. Further, it discusses the evidence supporting the potential clinical application of arterial biomarkers for the assessment of progression, severity, management and prognosis of aortic stenosis.

Ageing, hypertension and aortic valve stenosis - Understanding the series circuit using cardiac magnetic resonance and applanation tonometry

BACKGROUND

Aortic stenosis (AS) is no longer considered to be a disease of fixed left ventricular (LV) afterload, but rather, functions as a series circuit, with important contributions from both the valve and vasculature. Patients with AS are typically elderly, with hypertension and a markedly remodelled aorta. The arterial component is sizeable, and yet, quantifying this to-date has been difficult to determine. We compared measurement of aortic pressure, flow and global LV load using a cardiac magnetic resonance (CMR)/applanation tonometry (AT) technique to uncouple ventriculo-arterial (VA) interactions.

METHODS

20 healthy elderly patients and 20 with AS underwent a CMR/AT protocol. CMR provided LV volume and aortic flow simultaneously with AT pressure acquisition. Aortic pressure was derived by transformation of the AT waveform. Systemic vascular resistance (SVR) and global LV load were determined as the relationship of pressure to flow in the frequency domain. Values from both cohorts were compared.

RESULTS

AS patients were older (p ​< ​0.01) albeit with no significant difference in brachial or central aortic pressure. SVR (14228 vs 19906 ​dyne ​s.cm-3; p ​= ​0.02) and load (740 vs 946 ​dyne ​s.cm-3; p ​= ​0.02) were higher in patients with AS, whilst aortic peak flow velocity was lower (38 vs 58 ​cm/s; p ​< ​0.01).

CONCLUSIONS

Quantification of aortic pressure, flow velocity and global LV load using a simultaneous CMR/AT technique is able to demonstrate the progressive effects of hypertension and aortic stiffening with advanced age and valvular stenosis. This technique may help to better identify future patients at risk of VA coupling mismatch after correction of AS.

Hypertension in aortic stenosis: a focused review and recommendations for clinical practice

: In patients with aortic stenosis, the presence of hypertension negatively affects the hemodynamic severity of the stenosis, and worsens adverse left ventricular remodeling. It accelerates the progression of the stenosis and is associated with worse prognosis. Proper management of hypertension is thus crucial but there are concerns about the safety and efficacy of antihypertensive medications as well as uncertainty about optimal blood pressure (BP) targets and their impact on left ventricular mass regression and survival benefits. In the present review, we discuss these issues based on the evidence available in the current literature. Focus is first directed on the consequences of a persistently elevated BP before and after surgical aortic valve replacement or transcatheter valve implantation, and the clinical significance of an abnormal BP response during exercise in patients with significant aortic stenosis. Available data on use of antihypertensive drugs are then critically addressed, the conclusion being that calcium channel blockers may be associated with lower survival, and that diuretics may have disadvantages in patients with left ventricular hypertrophy and smaller left ventricular cavity dimensions, β-blockers may be well tolerated and a better choice for patients with concomitant coronary artery disease and arrhythmias. Renin--angiotensin system blockers improve survival given either before or after valve intervention. Emphasis is placed on the fact that evidence is not derived from randomized trials but only from observational studies. Finally, we discuss the optimal SBP level to reach in patients with aortic stenosis. Again, randomized trials are not available but observational evidence suggests that values between 130 and 139 mmHg systolic and 70-90 mmHg diastolic might represent the best option, and lower BP targets should probably be avoided.

Validation study to determine the accuracy of central blood pressure measurement using the SphygmoCor XCEL cuff device in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Central aortic blood pressure could be helpful in the evaluation of patients with aortic stenosis (AS). The SphygmoCor XCEL device estimates central blood pressure (BP) measurement with its easy‐to‐use, operator‐independent procedure. However, this device has not been properly validated against invasive measurement in patients with severe AS. We evaluated the relationship between cuff‐brachial BP, transfer function‐estimated and invasively measured central aortic pressure in patients with severe AS before and after transcatheter aortic valve replacement (TAVR). Agreement between techniques was analyzed and, according to the ARTERY Society recommendations, the minimum acceptable error was a mean difference ± SD ≤5 ± ≤8 mm Hg. A total of 94 patients with AS undergoing TAVR had simultaneous non‐invasive and invasive measurements of central BP before and after the procedure. Before TAVR central systolic BP was in average slightly underestimated, though with wide variability, when using the default calibration of brachial‐cuff SBP (mean difference ± SD, −3 ± 15 mm Hg), and after TAVR the degree of underestimation increased (mean difference ± SD, −9 ± 13 mm Hg). The agreement tended to improve for those patients with low aortic gradient stenosis compared to those with high gradient at baseline (mean difference ± SD, −2 ± 11 mm Hg vs. −4 ± 17, respectively, p = .3). The cuff‐brachial systolic BP yielded numerically lower degree of agreement and weaker correlation with invasive measurements than SphygmoCor XCEL. In patients with severe AS the SphygmoCor XCEL cuff device, despite showing strong correlation, does not meet the ARTERY Society accuracy criteria for non‐invasive measurement of central SBP.

Prognostic significance of vascular and valvular calcifications in low- and high-gradient aortic stenosis

AIMS

In low-gradient aortic stenosis (LGAS), the high valvulo-arterial impedance observed despite low valvular gradient suggests a high vascular load. Thoracic aortic calcifications (TACs) and valvular aortic calcifications (VACs) are, respectively, surrogates of aortic load and aortic valvular gradient. The aim of this study was to compare the respective contributions of TAC and VAC on 3-year cardiovascular (CV) mortality following TAVI in LGAS vs. high-gradient aortic stenosis (HGAS) patients.

METHODS AND RESULTS

A total of 1396 consecutive patients were included. TAC and VAC were measured on the pre-TAVI CT-scan. About 435 (31.2%) patients had LGAS and 961 (68.8%) HGAS. LGAS patients were more prone to have diabetes, coronary artery disease (CAD), atrial fibrillation (AF), and lower left ventricular ejection fraction (LVEF), P<0.05 for all. During the 3 years after TAVI, 245(17.8%) patients experienced CV mortality, 92(21.6%) in LGAS and 153(16.2%) in HGAS patients, P=0.018. Multivariate analysis adjusted for age, gender, diabetes, AF, CAD, LVEF, renal function, vascular access, and aortic regurgitation showed that TAC but not VAC was associated with CV mortality in LGAS, hazard ratio (HR) 1.085 confidence interval (CI) (1.019-1.156), P=0.011, and HR 0.713 CI (0.439-1.8), P=0.235; the opposite was observed in HGAS patients with VAC but not TAC being associated with CV mortality, HR 1.342 CI (1.034-1.742), P=0.027, and HR 1.015 CI (0.955-1.079), P=0.626.

CONCLUSION 

TAC plays a major prognostic role in LGAS while VAC remains the key in HGAS patients. This confirms that LGAS is a complex vascular and valvular disease.

Arterial Stiffness Changes in Severe Aortic Stenosis Patients Submitted to Valve Replacement Surgery

BACKGROUND

Little is known about the impact of severe aortic stenosis (AS) in aortic stiffness and if there is any change after removing AS barrier with aortic valve replacement (AVR) surgery.

OBJECTIVE

To estimate carotid-femoral pulse wave velocity (PWV) changes after AVR surgery and to define PWV predictors in severe AS patients.

METHODS

Single-center retrospective cohort, including patients with severe AS who underwent AVR surgery with bioprostheses, between February 2017 and January 2019 and performed PWV measurements (Complior®) before and after the procedure (2±1 months). Before and after AVR, PWV values were compared through paired tests. The associations of PWV with clinical data were studied and linear regression models were applied to estimate pre and postoperative PWV independent predictors. The significance level was set at 5%.

RESULTS

We included 150 patients in the sample, with mean age of 72±8 years, and 51% being males. We found a statistically significant increase in PWV values after surgery (9.0±2.1 m/s vs. 9.9±2.2, p<0.001, before and after AVR, respectively) and an inverse association with AS severity variables. In the linear regression model, age and systolic blood pressure (SBP) were established as independent predictors of higher pre- and postoperative PWV, while higher mean valvular gradient emerged as a determinant of lower pre-AVR PWV.

CONCLUSION

We documented an inverse correlation of arterial stiffness with the severity of AS in patients with AS, and a significant increase in PWV values after AVR surgery. Advanced age and higher SBP were associated with higher PWV values, although arterial function measurements were within the normal range. (Arq Bras Cardiol. 2021; 116(3):475-482).

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Prognostic impact of arterial stiffness following transcatheter aortic valve replacement

BACKGROUND

Increased left ventricular (LV) afterload in patients with aortic stenosis consists of valvular and vascular loads; however, the effects of vascular load induced by arterial stiffness on clinical outcomes after transcatheter aortic valve replacement (TAVR) remain unclear. This study evaluated the prognostic value of brachial-ankle pulse wave velocity (baPWV) after TAVR.

METHODS

A retrospective study including 161 consecutive patients who underwent TAVR with a pre-procedural baPWV assessment was conducted. We investigated the association between baPWV and the 1-year composite outcome comprising all-cause death and rehospitalization related to heart failure. Echocardiographic measurements including the LV mass index (LVMi) and LV diastolic function at 1, 6, and 12 months after TAVR were assessed.

RESULTS

Of the 161 patients, 31 patients experienced composite outcome within 1 year after TAVR. The receiver operating characteristic curve analysis revealed that the discriminating baPWV level to discern 1-year composite outcome was 1,639 cm/s, and all subjects were allocated to two groups based on the result. Baseline characteristics were comparable between the high baPWV (n = 72) and low baPWV groups (n = 89). The Kaplan-Meier curve revealed a significantly higher cumulative 1-year composite outcome in the high baPWV group than in the low baPWV group (31% vs. 10%; log-rank test, p<0.001). High baPWV was an independent predictor of the 1-year composite outcome (adjusted hazard ratio, 3.42; 95% confidence interval, 1.62-7.85; p = 0.002). Furthermore, post-procedural echocardiography revealed that the high baPWV group had less LVMi regression and higher E/e' after TAVR compared to the low baPWV group. The delayed reversal in LVMi and diastolic function attributable to arterial stiffness might be linked to impaired clinical outcomes after TAVR.

CONCLUSIONS

Higher baPWV could be associated with adverse clinical outcomes and delayed reverse LV remodeling after TAVR.

Impact of transcatheter aortic valve implantation on left ventricular function recovery, mass regression and outcome in patients with aortic stenosis: protocol of the TAVI-NOR prospective study

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is a widely used treatment option as an alternative to surgical aortic valve replacement in patients with severe aortic stenosis (AS) at high or intermediate surgical risk. TAVI improves symptoms, induces reverse left ventricular (LV) remodelling and increases overall survival. However, a careful patient selection is essential to achieve better outcome. Evidence on LV functional recovery and LV mass regression after TAVI based on contemporary registry data is scarce. The impact of TAVI on the arterial vasculature is also less explored.

METHOD AND ANALYSES

This is a study of 600 consecutive patients with AS who underwent a TAVI at Haukeland University Hospital, Bergen, Norway. Demographics, clinical data, arterial haemodynamics and echocardiographic parameters were prospectively collected. In the present paper, we describe the design, major scientific objectives and echocardiography imaging protocol of the TAVI-NOR (TAVI in western NORway) study. The main objectives are: To explore the impact of TAVI on cardiac structure and function in patients with severe AS, identify the echocardiographic predictors of reverse LV remodelling, assess survival benefits according to baseline risk profile, evaluate long-term therapeutic success as reflected by reduction in valvular-arterial impedance and to investigate the impact of various types of blood pressure response immediately after TAVI on clinical outcome.

ETHICS AND DISSEMINATION

The study was approved by the Regional Committees for Medical and Health Research Ethics (REK vest, ref. number 33814) and the Institutional Data Protection Services. Patients' consent was waived. The study findings will be disseminated via peer-reviewed publications and presentation in national and international scientific meetings and conferences.

TRAIL REGISTRATION NUMBER

The study was registered in the international database: ClinicalTrials.gov, Identifier: NCT04417829.

A novel method to assess valvulo-arterial load in patients with aortic valve stenosis

INTRODUCTION

Ventricular function in elderly patients with aortic stenosis is impeded both by restricted aortic flow and arterial stiffening. A number of patients continue to have exertional intolerance after relief of aortic valvular obstruction due to unrecognized ventriculo-arterial coupling mismatch.

HYPOTHESIS

Quantification of valvulo-arterial load (VAL), using a simultaneous applanation tonometry/cardiac magnetic resonance (CMR) technique, can accurately assess the relative contributions of aortic stiffness and valve gradient in older patients with aortic stenosis.

METHODS

Elderly patients with aortic stenosis underwent a simultaneous applanation tonometry/CMR protocol. CMR provided left ventricular volume and aortic flow simultaneously with radial applanation tonometry pressure acquisition. Central aortic pressure was derived by transformation of the radial applanation tonometry waveform. VAL was determined as the relationship of derived aortic pressure to CMR aortic flow in frequency domain (central illustration).

RESULTS

Twenty patients (age 80 ± 9 years; 12 males; blood pressure 140/75 ± 20 mmHg) with aortic stenosis on transthoracic echocardiogram (16 severe; mean gradient 45 ± 16 mmHg; aortic valve area 0.8 ± 0.2 cm2) were enrolled. Derived aortic pressure and flow waveforms correlated well with invasive data. Increased VAL was significantly associated with advanced age (P = 0.04) and raised SBP (P < 0.01), irrespective of aortic stenosis severity.

CONCLUSION

Difficulties in the measurement and accuracy of ventriculo-arterial coupling means that it is not routinely measured in patients with aortic stenosis. We describe a new noninvasive index that provides an accurate assessment of valvular and arterial load on the left ventricle. VAL may help detect those at risk of ventriculo-arterial coupling mismatch and assist in selection of those most likely to benefit from an invasive procedure.

Association of Natriuretic Peptide Levels After Transcatheter Aortic Valve Replacement With Subsequent Clinical Outcomes

Importance

Among those with aortic stenosis, natriuretic peptide levels can provide risk stratification, predict symptom onset, and aid decisions regarding the timing of valve replacement. Less is known about the prognostic significance and potential clinical utility of natriuretic peptide levels measured after valve replacement.

Objective

To determine the associations of elevated B-type natriuretic peptide (BNP) levels after transcatheter aortic valve replacement (TAVR) and change in BNP levels between follow-up time points with risk of subsequent clinical outcomes.

Design, Setting, and Participants

In this cohort study, patients with severe symptomatic aortic stenosis at intermediate, high, or prohibitive surgical risk for aortic valve replacement who underwent TAVR from the PARTNER IIA cohort, PARTNER IIB cohort, SAPIEN 3 intermediate-risk registry, and SAPIEN 3 high-risk registry were included. B-type natriuretic peptide levels were obtained at baseline and discharge as well as 30 days and 1 year after TAVR. For each measurement, a BNP ratio was calculated using measured BNP level divided by the upper limit of normal for the assay used. Outcomes were evaluated in landmark analyses out to 2 years. Data were collected from April 2011 to January 2019.

Main Outcomes and Measures

All-cause death, cardiovascular death, rehospitalization, and the combined end point of cardiovascular death or rehospitalization.

Results

Among 3391 included patients, 1969 (58.1%) were male, and the mean (SD) age was 82 (7.5) years. Most patients had a BNP ratio greater than 1 at each follow-up time point, including 2820 of 3256 (86.6%) at baseline, 2652 of 2995 (88.5%) at discharge, 1779 of 2209 (80.5%) at 30 days, and 1799 of 2391 (75.2%) at 1 year. After adjustment, every 1-point increase in BNP ratio at 30 days (approximately equivalent to an increase of 100 pg/mL in BNP) was associated with an increased hazard of all-cause death (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.07-1.15), cardiovascular death (aHR, 1.16; 95% CI, 1.11-1.21), and rehospitalization (aHR, 1.08; 95% CI, 1.03-1.14) between 30 days and 2 years. Among those with a BNP ratio of 2 or more at discharge, after adjustment, every 1-point decrease in BNP ratio between discharge and 30 days was associated with a decreased hazard of all-cause death (aHR, 0.92; 95% CI, 0.88-0.96) between 30 days and 2 years.

Conclusions and Relevance

Elevated BNP levels after TAVR was independently associated with increased subsequent mortality and rehospitalizations. Further studies to determine how best to mitigate this risk are warranted.

Ventricular stroke work and vascular impedance refine the characterization of patients with aortic stenosis

Aortic stenosis (AS) management is classically guided by symptoms and valvular metrics. However, the natural history of AS is dictated by coupling of the left ventricle, aortic valve, and vascular system. We investigated whether metrics of ventricular and vascular state add to the appreciation of AS state above valve gradient alone. Seventy patients with severe symptomatic AS were prospectively followed from baseline to 30 days after transcatheter aortic valve replacement (TAVR). Quality of life (QOL) was assessed using the Kansas City Cardiomyopathy Questionnaire. Left ventricular stroke work (SW_LV) and vascular impedance spectrums were calculated noninvasively using in-house models based on central blood pressure waveforms, along with hemodynamic parameters from echocardiograms. Patients with higher preprocedural SW_LV and lower vascular impedance were more likely to experience improved QOL after TAVR. Patients fell into two categories: those who did and those who did not exhibit increase in blood pressure after TAVR. In patients who developed hypertension (19%), vascular impedance increased and SW_LV remained unchanged (impedance at zeroth harmonic: Z ₀, from 3964.4 to 4851.8 dyne·s/cm³, P = 0.039; characteristic impedance: Z _c, from 376.2 to 603.2 dyne·s/cm³, P = 0.033). SW_LV dropped only in patients who did not develop new hypertension after TAVR (from 1.58 to 1.26 J; P < 0.001). Reduction in valvular pressure gradient after TAVR did not predict change in SW_LV (r = 0.213; P = 0.129). Reduction of SW_LV after TAVR may be an important metric in management of AS, rather than relying solely on the elimination of transvalvular pressure gradients.

The impact of transcatheter aortic valve implantation on arterial stiffness and wave reflections

BACKGROUND

The study of arterial properties in patients with aortic valve stenosis who undergo transcatheter aortic valve implantation (TAVI) remains challenging and results so far seem equivocal. We sought to investigate the acute and long-term effect of TAVI on arterial stiffness and wave reflections.

METHODS

We enrolled 90 patients (mean age 80.2 ± 8.1 years, 50% males) with severe symptomatic aortic stenosis undergoing TAVI. Arterial stiffness was assessed by carotid-femoral and brachial-ankle pulse wave velocity (cfPWV and baPWV). Augmentation index corrected for heart rate (AIx@75), central pressures and subendocardial viability ratio (SEVR) were assessed with arterial tonometry. Measurements were conducted at baseline, after TAVI and at 1 year.

RESULTS

Immediately after TAVI there was an increase in arterial stiffness (7.5 ± 1.5 m/s vs 8.4 ± 1.7 m/s, p = .001 for cfPWV and 1773 ± 459 vs 2383 ± 645 cm/s, p < .001 for baPWV) that was retained at 1 year (7.5 ± 1.5 m/s vs 8.7 ± 1.7 m/s, p < .001 and 1773 ± 459 cm/s vs 2286 ± 575, p < .001). Post-TAVI we also observed a decrease in AIx@75 (32.2 ± 12.9% vs 27.9 ± 8.4%, p = .016) that was attenuated 1 year later (32.2 ± 12.9% vs 29.8 ± 9.1%, p = .38), and an increase in SEVR (131.2 ± 30.0% vs 148.4 ± 36.1%, p = .002), which remained improved at 1 year (131.2 ± 30.0% vs 146.0 ± 32.2%, p = .01).

CONCLUSIONS

After TAVI the arterial system exhibits an increase of stiffness in response to the acute relief of the obstruction, which is retained in the long term.

Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension

BACKGROUND

Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve.

OBJECTIVE

To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease.

METHODS

We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease.

RESULTS

Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis.

CONCLUSION

Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.

Management of patients with combined arterial hypertension and aortic valve stenosis: a consensus document from the Council on Hypertension and Council on Valvular Heart Disease of the European Society of Cardiology, the European Association of Cardiovascular Imaging (EACVI), and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Aortic valve stenosis (AS) is the third most common cardiovascular disease. The prevalence of both AS and arterial hypertension increases with age, and the conditions therefore often co-exist. Co-existence of AS and arterial hypertension is associated with higher global left ventricular (LV) pressure overload, more abnormal LV geometry and function, and more adverse cardiovascular outcome. Arterial hypertension may also influence grading of AS, leading to underestimation of the true AS severity. Current guidelines suggest re-assessing patients once arterial hypertension is controlled. Management of arterial hypertension in AS has historically been associated with prudence and concerns, mainly related to potential adverse consequences of drug-induced peripheral vasodilatation combined with reduced stroke volume due to the fixed LV outflow obstruction. Current evidence suggests that patients should be treated with antihypertensive drugs blocking the renin-angiotensin-aldosterone system, adding further drug classes when required, to achieve similar target blood pressure (BP) values as in hypertensive patients without AS. The introduction of transcatheter aortic valve implantation has revolutionized the management of patients with AS, but requires proper BP management during and following valve replacement. The purpose of this document is to review the recent evidence and provide practical expert advice on management of hypertension in patients with AS.

Acute Effects of Transcatheter Aortic Valve Replacement on Central Aortic Hemodynamics in Patients With Severe Aortic Stenosis

Severe aortic stenosis induces abnormalities in central aortic pressure, with consequent impaired organ and tissue perfusion. Relief of aortic stenosis by transcatheter aortic valve replacement (TAVR) is associated with both a short- and long-term hypertensive response. Counterintuitively, patients who are long-term normotensive post-TAVR have a worsened prognosis compared with patients with hypertension, yet the underlying mechanisms are not understood. We investigated immediate changes in invasively measured left ventricular and central aortic pressure post-TAVR in patients with severe aortic stenosis using aortic reservoir pressure, wave intensity analysis, and indices of aortic function. Fifty-four patients (mean age 83.6±6.2 years, 50.0% female) undergoing TAVR were included. We performed reservoir pressure and wave intensity analysis on invasively acquired pressure waveforms from the ascending aorta and left ventricle immediately pre- and post-TAVR. Following TAVR, there were increases in systolic, diastolic, mean, and pulse aortic pressures (all P<0.05). Post-TAVR reservoir pressure was unchanged (54.5±12.4 versus 56.6±14.0 mm Hg, P=0.30) whereas excess pressure increased 47% (29.0±10.9 versus 42.6±15.5 mm Hg, P<0.001). Wave intensity analysis (arbitrary units, au) demonstrated increased forward compression wave (64.9±35.5 versus 124.4±58.9, ×10³ au, P<0.001), backward compression wave (11.6±5.5 versus 14.4±6.9, ×10³ au, P=0.01) and forward expansion wave energies (43.2±27.3 versus 82.8±53.1, ×10³ au, P<0.001). Subendocardial viability ratio improved with aortic function effectively unchanged post-TAVR. Increased central aortic pressure following TAVR relates to increased transmitted power and energy to the proximal aorta with increased excess pressure but unchanged reservoir pressure. These changes provide a potential mechanism for the improved prognosis associated with relative hypertension post-TAVR.