Short-term effects of transcatheter aortic valve replacement on blood pressure and cardiac function in elderly patients with severe aortic stenosis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a standard treatment for elderly and high-risk patients with aortic valve stenosis (AS); however, its short-term effects on blood pressure (BP) and cardiac function are not clear. Therefore, we aimed to determine the short-term effects of TAVR in elderly patients (>75 years), who reflect the clinical situation in Japan.

METHOD AND RESULTS

Twenty-eight consecutive elderly patients with severe AS and hypertension who underwent TAVR under general anesthesia were retrospectively investigated. All patients had hypertension that was well controlled with antihypertensive drugs. Serum brain natriuretic peptide level and peak velocity in the aortic valve were significantly reduced. TAVR induces an increase in BP that requires additional antihypertensive agents. There was no correlation between the change rate of SBP and stroke volume index (SVI), but there was a positive correlation between the rate of change in pulse pressure (PP) and SVI. This tendency was particularly observed in patients with low brachial-ankle pulse wave velocity (baPWV).

CONCLUSION

We observed post-TAVR hypertension and required additional antihypertensive drugs. The increases in SVI and PP after TAVR resulted in post-TAVR hypertension. Moreover, post-TAVR hypertension is less likely to occur in elderly patients with a high baPWV, which indicates advanced arteriosclerosis.

Integrating hemodynamics with ventricular and valvular remodeling in aortic stenosis. A paradigm shift in therapeutic decision making

Aortic valve stenosis (AS) has traditionally been approached in hemodynamic terms. Although hemodynamics and symptoms have formed the basis of recommending interventional treatment in AS, other factors reflecting left ventricular and valvular and/or vascular remodeling are equally important for the prognosis and outcome of patients with AS. Left ventricular and valvular/vascular remodeling in AS do not consistently correlate with hemodynamic severity of AS. Those remodeling changes are reflected and can be detected by a variety of novel laboratory and imaging techniques, including biomarkers, echocardiography, cardiac magnetic resonance and gated Computer Tomography (CT) imaging. Taking all those elements into Heart Team therapeutic decision making in patients with AS, can significantly improve appropriate patient selection for interventional treatment and patient outcomes. We review this novel approach and propose a simple algorithm for decision making by the Heart Team, in patients with moderate or severe AS.

Echocardiographic assessment of diastolic dysfunction in elderly patients with severe aortic stenosis before and after aortic valve replacement

Background

The 2016 guidelines of the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) for evaluation of left ventricular (LV) diastolic dysfunction by Doppler flow and tissue Doppler- echocardiography do not adjust assessment of high filling pressures for patients with aortic stenosis (AS). However, most of the studies on this patient group indicate age independent specific diastolic features in AS. The aim of this study is to identify disease-specific range and distribution of diastolic functional parameters and their ability to identify high N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels as a marker for high filling pressures.

Methods

In this study, 169 patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Resting echocardiography was performed including Doppler of the mitral inflow, pulmonary venous flow, tricuspid regurgitant flow and tissue Doppler in the mitral ring and indexed volume-estimates of the left atrium (LAVI). Echocardiography, and NT-proBNP levels were assessed before TAVR/SAVR and at two postoperative visits at 6 and 12 months.

Results

Pre- and postoperative values were septal e′; 5.1 ± 3.9, 5.2 ± 1.6 cm/s; lateral e′ 6.3 ± 2.1; 7.7 ± 2.7 cm/s; E/e′19 ± 8; 16 ± 7 cm/s; E velocity 96 ± 32; 95 ± 32 cm/s; LAVI 39 ± 8; 36 ± 8 ml/m², pulmonary artery pressure (PAP) 39 ± 8; 36 ± 8 mmHg, respectively. The scoring recommended by ASE/EACVI detected elevated NT pro-BNP with a specificity of 25%. Adjusting thresholds towards PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E deceleration time < 220 ms, and E/septal e′ ≥ 20 or septal e′ < 5.0 cm/s increased prediction of NT-proBNP levels ≥500 ng/L with substantially improved specificity (> 85%).

Conclusion

Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and NT-proBNP indicate elevated filling pressures in most of the patients, improving only modestly 6–12 months after TAVR and SAVR. Applying the 2016 ASE/EACVI recommendations for detection of elevated filling pressures to patients with AS, elevated NT pro-BNP levels could not be reliably detected. However, adjusting thresholds of the echocardiographic parameters increased specificities to useful diagnostic levels.

Trial registration

The study was prospectively approved by the regional ethical committee, REK North with the registration number: REK 2010/397-10.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00262-1.

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

We sought to assess the impact of diastolic dysfunction (DD) grade, as per the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, on survival of patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve implantation (TAVI). We included consecutive patients with severe AS who underwent TAVI in our institution. DD grading was determined retrospectively according to the 2016 ASE DD guidelines and categorized to grade I-III and indeterminate grade I-II DD. Comparison of 1-year survival according to DD grade was performed by Kaplan-Meier analysis, and evaluation of DD at 1 year was performed in a subset of patients. Among 606 TAVI patients, 394 (65%) had sufficient data for DD grading. Seventy-seven (20%) had grade I DD, 191 (48%) had grade II, 60 (15%) had grade III, and 66 (17%) had an indeterminate grade between I and II. Baseline characteristics indicate higher rates of atrial fibrillation, brain natriuretic peptide level, pulmonary artery systolic pressure, and indexed left ventricular mass as DD grade increases (all p ≤0.01). In conclusion, comparison of 1-year survival revealed a higher rate of mortality in patients with grade III DD that remained statistically significant following adjustment in a multivariate Cox proportional hazard model. DD grade after TAVI improved in patients with grades II and III. Severe AS patients with grade III DD have higher risk for 1-year mortality after TAVI compared with milder degrees of DD. Further research is warranted to explore a potential benefit for aortic valve therapy at an earlier stage of the disease process.