The impact of chronic obstructive pulmonary disease on right ventricular dysfunction and remodeling after aortic valve replacement

Background

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in patients with aortic stenosis (AS) and has been associated with a poor prognosis after both transcatheter and surgical aortic valve replacement (AVR). Since COPD is associated with an increase in right ventricular (RV) afterload, some studies already suggested that COPD causes RV dysfunction (RVD) and dilatation. On the other hand, RVD and remodeling can also occur due to chronic pressure overload secondary to the AS itself. However, there is no data that studied RVD and remodeling in AVR recipients in terms of COPD severity.

Purpose

We aimed to evaluate the impact of COPD on RVD and remodeling in patients with severe AS undergoing AVR before AVR and at 1-year follow-up, as well as the association between COPD severity and all-cause mortality.

Methods

Patients with severe AS who received either transcatheter or surgical AVR were included. Patients' demographic data, medical history and documented spirometry data were carefully collected, while two-dimensional and speckle tracking echocardiography measurements were performed according to recommended guidelines to evaluate RV systolic function and RV size. RVD was defined as tricuspid annular plane systolic excursion (TAPSE) ≤17mm. RV dilatation was defined by RV mid cavity >35 mm, RV basal diameter >42mm, and RV longitudinal diameter >83mm. RV wall thickness above 5mm was considered as RV hypertrophy. Diagnosis of COPD was determined by the Society of Thoracic Surgeons' definition based on forced expiratory volume in first second (FEV 1<75%, cut-off for COPD). The primary outcome was all-cause death at 1-year.

Results

A total of 293 patients (78.0 years, 58.4% male) were included. RVD was detected in 54 (18.4%) patients, while 55 (18.8%) patients had mild COPD and 43 (14.7%) patients had moderate or severe COPD. At 1-year follow-up, the prevalence of RVD significantly increased (18.4% versus 23.6%, p=0.004). Compared to baseline, RV free wall strain of lateral basal segment (p=0.046), TAPSE (p<0.0001) and tricuspid regurgitation gradient (p=0.018) impaired whereas RV wall thickness (p=0.014), RV diameter index of lateral basal segment (p<0.0001), and RV diameter index of lateral mid segment (p<0.0001) increased, respectively. At 1-year follow-up, 33 patients died (Figure 1). On multivariate cox regression analysis, RVD (hazard ratio (HR) 2.781, 95% confidence interval (CI) 1.172–6.598; p=0.020) as well as mild (HR 4.695, 95% CI 1.787–12.336; p=0.002) and moderate-severe COPD (HR 4.725, 95% CI 1.717–13.006; p=0.003) were significantly associated with the endpoint (Table 1).

Conclusions

The prevalence of RVD significantly increased and it deteriorated at 1-year after AVR. RV remodeling observed more at lateral basal and mid segments of RV as well as wall thickness. RV dysfunction and COPD were the strongest predictors of mortality in this population.

Funding Acknowledgement

Type of funding sources: None.

Association between chronic obstructive pulmonary disease and all-cause mortality after aortic valve replacement for aortic stenosis

Introduction

Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in aging population that their prevalence and percental change in mortality increase over the years. In severe AS, aortic valve replacement (AVR) is the only treatment that has demonstrated to improve survival, however the presence of comorbidities increases the operative risk and influences negatively on the outcomes after AVR. Therefore, the definition of COPD varies across the studies and is not always based on the use of pulmonary functional tests. Accordingly, the aim of the present study is to evaluate the association between pulmonary functional parameters and all-cause mortality after AVR in a large cohort of patients with severe AS.

Methods

Total of 400 patients (78.0 year-old, 56.7% men) with severe AS and documented preoperative pulmonary functional test (PFT) were retrospectively analyzed. Demographic and clinical characteristics were collected from electronic medical records while echocardiography was performed and measured according to the recommendations. PFTs were performed prior to AVR and categories defined in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database: normal pulmonary function was defined by an FEV1 >75% of predicted; mild COPD if FEV1 was 60–75% of predicted; moderate COPD if FEV1 was 50–59% of predicted and severe COPD when FEV1 <50% of predicted.

Results

Mild, moderate and severe COPD were documented in 75 (19%), 31 (8%) and 22 (5%) while the remaining 68% had normal PFTs. Patients with moderate and severe COPD had significantly larger LV mass and LV end-systolic volume whereas LV ejection fraction was significantly lower. The FVC, FEV1, Tiffeneau index, VC, PEF, and IC were the worst among patients with moderate and severe COPD (per definition) (p<0.0001). Over a median follow-up of 32 months, 92 (23%) patients died. The survival rates were significantly lower in patients with moderate and severe COPD (Log rank p=0.003, Figure 1). In multivariable Cox regression analysis, some clinical factors and COPD were independently associated with all-cause mortality (table 1). Remarkably, any grade of COPD was associated with 2-fold increased risk of all cause-mortality (HR 1.933; 95% CI 1.166–3.204; p=0.011 for mild COPD and HR 2.028; 95% CI 1.154–3.564; p=0.014 for moderate/ severe COPD, separately).

Conclusion

Patients with moderate and severe COPD had higher LV hypertrophy and reduced LV ejection fraction while PFT parameters were the worst among these patients. The survival rates were significantly lower in patients with moderate and severe COPD compared with patients without COPD. In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all cause-mortality.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of left ventricular myocardial work indices in patients undergoing transcatheter aortic valve replacement

Introduction

Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess LV function using pressure-strain loops taking LV afterload into account. In patients with aortic stenosis (AS), this approach was shown to improve assessment of LV performance as compared to conventional and advanced parameters of LV systolic function, but data on its prognostic value are lacking.

Purpose

To evaluate the prognostic value of LVMW indices in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).

Methods

LVMW indices, including LV global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were calculated in 281 patients with severe AS (age 82, IQR 78–85 years, 52% male) prior to the TAVR procedure. As previously validated, LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure. LV global longitudinal strain and LV systolic pressure were then incorporated to construct pressure-strain loops to determine the LVMW indices. The study endpoint was all-cause mortality.

Results

In the total population average GWI was 1872±753 mmHg%, GCW 2240±797 mmHg%, GWW 200 (IQR 127–306) mmHg% and GWE 89 (IQR 84–93)%. During a median follow-up of 52 (IQR 41–67) months, 64 patients died. These patients showed lower values of GWI (1644 vs 1940 mmHg%, p=0.006) and GCW (2010 vs 2307 mmHg%, p=0.009) as compared to patients who survived while GWW (197 vs 200 mmHg%, p=0.794) and GWE (88% vs 90%, p=0.102) were similar. While LV GCW, GWW and GWE did not show a significant association with the study endpoint, GWI was independently associated with all-cause mortality (HR per-tertile-increase 0.639; 95% CI 0.463–0.883; P=0.007), and the patients in the lowest GWI tertile showed the worst survival rates (Figure 1). Of interest, patients in the lowest GWI tertile were more likely to be male (63% vs 56% and 37% from the lowest to the highest tertile, P=0.001), had a higher prevalence of atrial fibrillation (26% vs 19% and 8% from the lowest to the highest tertile, P=0.006), worse renal function (53 mL/min/1.73 m2 vs 64 mL/min/1.73 m2 and 62 mL/min/1.73 m2 from the lowest to the highest tertile, P=0.038) and larger LV dimension (LVEDD 52 mm vs 47 mm and 46 mm from lowest through highest tertile, p<0.001). Importantly, when added to a basal model, LVGWI yielded a higher increase in predictivity compared to both conventional and advanced parameters of LV systolic function (Figure 2). Also, in a model corrected for the hemodynamic class of AS (high-gradient, low-flow low-gradient), GWI also showed a significant independent association (P=0.003) with all-cause mortality.

Conclusions

LVGWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.

Funding Acknowledgement

Type of funding sources: None.

Clinical decision making in frequently encountered anomalous aortic origin of coronary arteries, the impact of IVUS

Introduction

The aim in the diagnostic work-up of patients with an anomalous aortic origin of coronary arteries (AAOCA) is to determine whether the course of the coronary artery is benign or malignant. In patients with AAOCA with an interarterial course the guidelines on diagnostics are concise. Recommended CT-scan imaging does not evaluate stress-induced functional consequences like external compression by the pulmonary artery as the scan is performed in a resting state. Non-invasive ischemia detection techniques often lack sufficient sensitivity. To improve functional stratification, exploration of new diagnostic modalities in the diagnostic workup of AAOCA is mandatory.

Purpose

The purpose is to explore the potential role of intravascular ultrasound (IVUS) in the diagnostic workup of patients with AAOCA.

Methods

Nine patients with an anomalous right coronary artery with an interarterial course were analyzed. A cardiologist evaluated the complaints. Anatomical features of the AAOCA were assessed with CT-scan imaging. Further analyses included ischemia detection and coronary angiography. To assess stress-induced ischemia IVUS and invasive measurements – fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) – were performed at rest and during adrenaline-induced stress. A slit-like orifice was classified as a width/length (W/L) ratio of ≤0.50, an oval orifice as 0.51–0.9 and a round orifice as >0.91.

Results

Potential cardiac complaints were present in seven patients. In 8 (89%) patients CT-images showed an acute angle, in 8 (89%) proximal narrowing and an aortic take-off above the pulmonary valve in 4 (44%). In 7 (78%) patients a slit-like orifice and in two (22%) an oval orifice were observed (table 1). IVUS at rest showed a slit-like orifice in one patient classified as an oval orifice on the CT-images and vice versa in another patient (table 2). The patients classified as an oval orifice with IVUS showed no external compression during adrenaline-induced stress. In 4 (57%) out of 7 patients with an slit-like orifice on IVUS, the width remained unchanged or increased during adrenaline infusion. In 2 patients the width decreased slightly, however, these patients were asymptomatic and no ischemia was detected. In 1 (14%) patient the width remained 1.4mmm and the length increased from 3.2mm to 4.7mm. In this case the vessel ostium was fully engaged with the IVUS catheter, hence, the width could not decrease during adrenaline infusion. This was regarded as external compression. In addition, in this patient ischemia was detected.

Conclusion(s)

In two (22%) out of 9 patients IVUS gave a better insight of the shape of the orifice than CT. Additionally, the anatomic and functional-dynamic components of compression could be defined with adrenaline-induced stress. Therefore, IVUS can contribute to a better understanding of the functional consequences of the anatomical features and of potential stress-induced external compression.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

P5606Incidence and clinical impact of type A aortic dissection detected during invasive coronary procedures. Results from an international, multicentre, all-comer registry

Background

Type A aortic dissection (AD) is an extremely severe condition with high mortality. Its clinical presentation may mimic other conditions such as myocardial ischemia. Furthermore, coronary hypoperfusion may occur. This may result in misdiagnosis and subsequent referral to the cath-lab, implying potential catastrophic consequences.

Purpose

To determine the incidence and clinical impact of type A AD detected at the cath-lab in all-comers referred for invasive coronary procedures (both diagnostic and therapeutic).

Methods and results

Data was obtained from three high-volume centers from different countries. 41.186 procedures performed in all-comers between 2011–2018 were analyzed, of which 20.067 (49%) were PCIs. Iatrogenic AD resulting from the procedure were excluded. In 17 patients (0.002%; age 75±11 years, 72% male) a type A AD was detected during the procedure. The diagnosis was established by aortic angiography in 15 (88%); in 2 (12%) the diagnosis was suspected based on difficult coronary cannulation or the presence of a fluoroscopically-visible fluttering flap, requiring confirmation with aortic imaging tests. The procedure was performed in a emergent fashion in 14 patients (89%): due to suspected acute coronary syndrome in 11 (65%) (8 [72%] STEMI and 3 [18%] NSTEMI) and because of out of hospital cardiac arrest in 4 (24%). Loading dose of antiplatelets (aspirin 76%, P2Y12 inhibitors 100%) and heparin (100%) were administered in the majority of patients. Either the left main or right coronary artery ostia were involved in 8 patients (47%), although in a significant number of cases coronary anatomy was not fully evaluated due to problematic cannulation of the coronary arteries (left main 18%, right coronary artery 30%). Previous history of aortic root dilatation was present in 5 cases (30%). None of the patients had previous history of connective tissue disorders or bicuspid aortic valve. CT scan was feasible in 9 cases (59%). A DeBakey type I AD was observed in 8 patients (47%) and a DeBakey type II in 9 cases (53%). Overall in-hospital mortality rate was 59% (10 patients). 3 patients (30%) died during the procedure. 10 (59%) underwent surgical treatment (4 of them with concomitant aortic valve replacement). Perioperative mortality rate was 30% (1 due to hemorrhagic stroke, 1 due to massive bleeding during surgery; 1 due to cardiac tamponade). All patients who were not candidates for surgery (7 cases, 41%) died during admission. Patients successfully discharged presented a median survival of 17 months (4–78).

Conclusions

The detection of a type A AD during invasive coronary procedures is rare and is predominantly observed in patients referred for urgent interventions. The overall in-hospital mortality is very high (59%) and therefore prompt identification by the operator is mandatory. Surgery, when feasible, is the treatment of choice, although perioperative mortality rate is high, mostly due to bleeding complications.

Acknowledgement/Funding

None