Effect of transcatheter aortic valve implantation on intraoperative left ventricular end-diastolic pressure

Abstract

Transcatheter aortic valve implantation (TAVI) for patients with aortic stenosis is a less invasive alternative to surgical aortic valve replacement. Despite this, careful anesthetic management, especially strict control of blood pressure and fluid management, is necessary. During TAVI, normalization of left ventricular afterload due to aortic balloon valvuloplasty and prosthetic valve deployment is expected to result in rapid improvement of systolic function and consequent improvement in diastolic function. However, the early effect of TAVI on left ventricular diastolic function is less clear. We hypothesized that TAVI induces a rapid decrease in left ventricular end-diastolic pressure (LVEDP) after valve deployment. This retrospective observational study included 71 patients who had undergone TAVI using the transfemoral approach with a balloon-expandable valve under general anesthesia. Intraoperative LVEDP was measured using an intracardiac catheter. The severity of residual aortic regurgitation (AR) was assessed using the Sellers criteria. The mean (SD) LVEDP was 17.8 (5.3) mmHg just before TAVI and increased significantly to 27.3 (8.2) mmHg immediately after prosthetic valve deployment (p < 0.0001). The change in LVEDP was 8.7 (8.6) mmHg in patients with low residual AR (Sellers ≤1) and 11.0 (7.1) mmHg in those with high residual AR (Sellers ≥2); however, this difference was not significant. No correlation was found between the LVEDP change and intraoperative fluid balance. In conclusion, LVEDP increased significantly in the early period after valve deployment during TAVI, regardless of residual AR severity. It was suggested that the tolerability of fluid load could be reduced at that time.

Acute haemodynamic impact of transcatheter aortic valve implantation in patients with severe aortic stenosis

“…Despite several studies aiming to compare non‐invasive (echocardiographic and cardiac magnetic resonance) pre‐TAVI and post‐TAVI data have been performed, poor data are available on the role of the haemodynamic assessment performed immediately before and after prosthesis deployment in patients with severe AS 15,16,35,36 …”

“…There are limited data regarding the invasive haemodynamic evaluation of patients undergoing TAVI and even less about the prognostic role of the haemodynamic study performed immediately before and after prosthesis deployment 15–20 . Most of the available invasive studies focused on right heart catheterization, 17–20 and the few studies performed with left heart catheterization (LHC) focused on the role of residual aortic regurgitation (AR) as predictor of long‐term mortality 21,22 …”

Early hemodynamic changes after transcatheter aortic valve implantation in patients with severe aortic stenosis measured by invasive pressure volume loop analysis

“…Our observations resemble the results of an observational study conducted by Toyota et al, who measured LVEDP during TAVI using an intracardiac catheter. The group described a mean LVEDP rise of 8.7 mmHg immediately after TAVI that was independent of paravalvular leakage or intraoperative fluid balance [ 25 ].…”

“…Hemodynamic changes of TAVI in patients with severe aortic stenosis and LV hypertrophy are usually well-tolerated and the need for hemodynamic support is rare in clinical practice. However, one possible explanation of the early negative side-effects may be the phenomenon of temporary myocardial stunning provoked by rapid ventricular pacing [ 24 , 25 ]. Myocardial stunning is characterized by a condition of postischemic mechanical dysfunction that persists after reperfusion despite the absence of irreversible injury [ 28 ].…”

Implante de prótesis valvular aórtica a través de catéter en pacientes con patología mitral concomitante

“…El área mitral efectiva no debería ser el parámetro utilizado para valorar prótesis y la ecuación de continuidad no es válida cuando existe enfermedad concomitante aórtica. El gradiente transmitral es el mejor parámetro para evaluar la correcta función y no varió significativamente tras el procedimiento en nuestra población (90). Sin embargo, casi un tercio de los pacientes presentaron un incremento del gradiente que se asoció con peor recuperación funcional, este hallazgo deberá ser estudiado más a fondo en futuras investigaciones.…”