Prognostic Importance of Diastolic Dysfunction in Relation to Post Procedural Aortic Insufficiency in Patients Undergoing Transcatheter Aortic Valve Replacement.

OBJECTIVES: We sought to examine whether baseline diastolic dysfunction (DD) is associated with increased mortality in patients who develop aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR). BACKGROUND: Significant post-TAVR AI is associated with increased mortality, likely secondary to adverse hemodynamics secondary to volume overload and decreased LV compliance from chronic pressure overload. However, the effect of baseline DD on outcomes of patients with post-TAVR AI has not been studied. METHODS: A total of 195 patients undergoing TAVR were included in the study. Patients with moderate-to-severe mitral stenosis, prior mitral valve replacement or atrial fibrillation were excluded. DD was classified at baseline by a 2-step approach as recommended by the American Society of Echocardiography while AI was evaluated 30 days post-TAVR. Follow up data up to 2 years post-TAVR was used in survival analysis. RESULTS: Patients with severe baseline DD who developed ≥mild post-TAVR AI had increased mortality compared to all other patients (HR = 3.89, CI: 1.76-8.6, P = 0.001), which remained significant after adjusting for post-TAVR AI, pre-TAVR AI, baseline mitral regurgitation, ejection fraction, pulmonary artery pressure, creatinine clearance and history of stroke. CONCLUSIONS: Even mild post-TAVR AI may have a negative impact on outcomes of patients with underlying severe DD. © 2016 Wiley Periodicals, Inc.

Impact of Paravalvular Aortic Insufficiency on Left Ventricular Remodeling and Mortality after Transcatheter Aortic Valve Replacement.

BACKGROUND: Paravalvular aortic regurgitation (PAR) remains a common complication following transcatheter aortic valve replacement (TAVR), and has been associated with increased mortality. Adverse left ventricular (LV) remodelling has been reported in patients with post-TAVR PAR, but the association between adverse LV remodeling and increased mortality remains unclear. The aim of the present study was to examine the association between PAR, LV remodeling and mortality following TAVR in a non-PARTNER (Placement of Aortic Transcatheter Valves) trial population. METHODS: A total of 195 patients that underwent TAVR was included in the study. The LV ejection fraction (LVEF), LV mass index (LVMI), LV internal dimension at systole (LVIDs) and diastole (LVIDd) were compared between patients with different degrees of PAR at baseline, and at one month and one year after TAVR. Survival analysis was performed for different degrees of PAR and LV remodeling. RESULTS: PAR ≥moderate was associated with increased mortality (HR 4.58 [1.80-11.63], p = 0.001), but PAR >mild was not. The LVIDd and LVIDs were persistently increased at one year after TAVR in patients with PAR >mild compared to those with PAR ≤mild (5.9 ± 0.8 cm versus 5.4 ± 0.7 cm, p = 0.02 and 4.4 ± 0.8 cm versus 3.9 ± 0.8, p = 0.03, respectively). The LVEF was improved similarly between the two groups at one year after TAVR (p = 0.1). Patients with PAR ≥moderate had significantly more adverse LV remodeling at one month after TAVR in terms of LVIDd, LVIDs, and LVMI. The degree of remodeling as expressed in terms of LVIDd, LVIDs, LVMI and LVEF changes from baseline did not have a direct impact on mortality. CONCLUSIONS: A worse PAR was associated with more adverse LV remodeling and a higher mortality after TAVR in a non-PARTNER patient population.

Absence of electrocardiographic left ventricular hypertrophy is associated with increased mortality after transcatheter aortic valve replacement.

BACKGROUND: Electrocardiographic (ECG) left ventricular hypertrophy (LVH) has been associated with increased mortality in patients with asymptomatic aortic stenosis (AS) and hypertension. However, patients with symptomatic AS undergoing transcatheter aortic valve replacement (TAVR) have higher percentages of myocardial fibrosis or amyloidosis that have been associated with decreased ECG voltage and worse outcomes. HYPOTHESIS: We tested the hypothesis that baseline ECG LVH is independently associated with increased all-cause mortality after TAVR. METHODS: A total of 231 patients (96 men; mean age 84.7 ± 7.8 years) that underwent TAVR at our institution were included. Cornell voltage, defined as SV3 + RaVL, was used to assess for presence of ECG LVH using gender-specific cut-off values. We used the Kaplan-Meier estimator to derive survival curves. Multivariate Cox regression analysis was used to compare mortality between patients without vs with ECG LVH and adjust for echocardiographic LVH and predictors of mortality in this cohort. RESULTS: Over a follow-up time of 16.3 ± 10.4 months, the absence of ECG LVH was significantly associated with increased mortality (40.4% vs 23.6% at 2-years, log rank P = 0.003). After adjusting for echocardiographic LVH and predictors of mortality in our cohort, the absence of ECG LVH remained a predictor of increased mortality (HR = 1.79, CI 95% 1.02-3.14, P = 0.042). CONCLUSIONS: The absence of ECG LVH was independently associated with increased mortality in patients undergoing TAVR. Baseline ECG may have an important prognostic role in these patients and could lead to further testing to evaluate for myocardial fibrosis or amyloidosis.