Incidence and Risk Factors for Long-Term Persistence of Diastolic Dysfunction after Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation

Abstract

(1) Background: Severe left ventricular (LV) diastolic dysfunction with a restrictive diastolic pattern (LVDFP) is generally associated with a worse prognosis. Its evolution and reversibility in the short- and medium-term after aortic valve replacement (AVR) has been little-studied. We aimed to evaluate the evolution of LV remodeling and LV systolic and diastolic function after AVR in aortic stenosis (AS) patients compared to aortic regurgitation (AR). Moreover, we tried to identify the main predictive parameters for postoperative evolution (cardiovascular hospitalization or death and quality of life) and the independent predictors for the persistence of restrictive LVDFP after AVR. (2) Methods: A five-year prospective study on 397 patients undergoing AVR for AS (226 pts) or AR (171 pts), evaluated clinically and by echocardiography preoperatively and until 5 years postoperatively. (3) Results: 1. In patients with AS, early post AVR, LV dimensions decreased and diastolic filling and LV ejection fraction (LVEF) improved more rapidly compared to patients with AR. At 1 year postoperatively, persistent restrictive LVDFP was found especially in the AR group compared to the AS group (36.84% vs. 14.16%). 2. Cardiovascular event-free survival at the 5-year follow-up was lower in the AR group (64.91% vs. 87.17% in the AS group). The main independent predictors of short- and medium-term prognosis after AVR were: restrictive LVDFP, severe LV systolic dysfunction, severe pulmonary hypertension (PHT), advanced age, severe AR, and comorbidities. 3. The persistence of restrictive LVDFP after AVR was independently predicted by: preoperative AR, the E/Ea ratio > 12, the LA dimension index > 30 mm/m2, an LV endsystolic diameter (LVESD) > 55 mm, severe PHT, and associated second-degree MR (p < 0.05). (4) Conclusions: AS patients had an immediate postoperative evolution in terms of LV remodeling, and LV systolic and diastolic function were more favorable compared to those with AR. The restrictive LVDFP was reversible, especially after the AVR for AS. The main prognostic predictors were the presence of restrictive LVDFP, advanced age, preoperative AR, severe LV systolic dysfunction, and severe PHT.

Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function

“…In chronic aortic regurgitation, volume overload triggers cardiac remodelling characterized by LV dilatation and eccentric hypertrophy towards a more spherical shape 115 . AVR induces RR after successful surgery, leading to improved systolic and diastolic performance, New York Heart Association (NYHA) class, and quality of life 116,117 . Despite an early decrease in LVEF post‐AVR, significant improvement occurs within 1 year after surgery and persists thereafter, characterized by reductions in LV dimensions and a trend toward LVM regression 117–119 .…”

“…Despite an early decrease in LVEF post‐AVR, significant improvement occurs within 1 year after surgery and persists thereafter, characterized by reductions in LV dimensions and a trend toward LVM regression 117–119 . Preoperative indexed LV end‐systolic diameter or volume and LVEF independently predict incomplete RR, 118,119 while restrictive diastolic filling before AVR seems to impair LV RR 116 . Impairment of LV global work index post‐surgery is significantly associated with worse LV RR, possibly due to increased myocardial fibrosis 120 .…”

The Association Between Ascending Aortic and Left Ventricular Dimensions in Patients After Aortic Valve Replacement

“…These structural changes affect LV mechanics, and although LV ejection fraction (LVEF) may remain preserved for a considerable period, LV diameter may be compromised at earlier stages. As a result, patients with severe AS or AR may tolerate the volume overload state for many years and remain asymptomatic even after the development of LV dilatation and dysfunction [ 5 ] .…”

Effect of Pulmonary Hypertension on Survival Outcomes in Patients With Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

“…While TAVI emerges as a safe and efficacious treatment for AS, surpassing SAVR in attention, the heightened perioperative risk posed by PH necessitates thorough investigation into its balance of benefits and risks within this patient cohort [5]. Patients with PH undergoing TAVR may encounter elevated rates of post-procedure complications, prolonged hospital stays, increased mortality, and diminished functional outcomes compared to their counterparts without PH [6]. These findings underscore the importance of meticulous evaluation and management of PH in TAVR patients to optimize outcomes and enhance patient care.…”