Prevalence and Prognostic Significance of Right Ventricular Systolic Dysfunction in Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract

T ranscatheter aortic valve implantation (TAVI) is as an effective treatment alternative for patients with severe aortic stenosis who are either inoperable or high risk, for surgical aortic valve replacement (AVR).1,2 Several short-term 3 and medium-term 4 outcome studies have consistently demonstrated good clinical outcomes after TAVI, findings that have been reinforced by more recent long-term follow-up data. 5,6 As a result, the number of TAVI implants performed worldwide continues to grow year on year. Several imaging techniques can be used to assess whether a patient is suitable for TAVI 8 ; echocardiography remains the fundamental method of assessing the severity of aortic valve disease, permitting measurements of left ventricular (LV) and right ventricular (RV) functions, aortic valve area (AVA), mean and peak pressure gradients across the aortic valve, and myocardial mass.9 Two other imaging modalities are widely used in the preassessment of potential TAVI patients: multislice computerized tomography, which provides information on aortic annular Background-Cardiovascular magnetic resonance (CMR) can provide important structural information in patients undergoing transcatheter aortic valve implantation. Although CMR is considered the standard of reference for measuring ventricular volumes and mass, the relationship between CMR findings of right ventricular (RV) function and outcomes after transcatheter aortic valve implantation has not previously been reported. Methods and Results-A total of 190 patients underwent 1.5 Tesla CMR before transcatheter aortic valve implantation.Steady-state free precession sequences were used for aortic valve planimetry and to assess ventricular volumes and mass.

Right ventricular mechanics in patients with aortic stenosis and preserved ejection fraction: Is arterial hypertension a new player in the game?

“…The RV function was proved to be an important predictive factor of mortality in patients after transcatheter aortic valve implantation (TAVI) . However, Lindsay et al used cardiac magnetic resonance (CMR) and RV ejection fraction for the assessment of RV function, and not echocardiographic evaluation as in our study. Musa et al also used CMR as a referent method showing that RV mass was the only independent predictor of mortality after TAVI procedure.…”

“…However, studies have shown that its structure and function is very important in patients with congenital heart disease and pulmonary hypertension, but afterward, the important role of RV remodeling has been proved in the patients with heart failure, heart transplantation, cardiomyopathies, and valvular heart disease . The influence of aortic stenosis (AS) and particularly of AS severity on RV remodeling is still debatable, and the data are scarce . Recently, several studies regarding the prognostic importance of RV structure and function in AS patients after surgical replacement or catheter aortic valve implantation have been published …”

Echocardiographic follow‐up after transcatheter aortic valve replacement

“…Studies assessing RV size and function by echocardiography found that larger basal‐ and mid‐RV diameter, but not RV dysfunction (assessed by TAPSE or fractional area change), were independently associated with increased mortality . In contrast, RV ejection fraction ≤50%, but not the end‐systolic or end‐diastolic volumes, by CMR was independently associated with impaired survival (HR=2.12, P =.017) of patients who underwent TAVR . Furthermore, when evaluated by CMR or 3D echocardiography, RV function was reported to remain unchanged after TAVR, in comparison with reduced RV ejection fraction after surgical valve replacement …”

“…Few studies have assessed right ventricular (RV) function in patients undergoing TAVR, and they have provided controversial results mainly depending on the chosen imaging modality. Emerging studies demonstrate that RV dysfunction (assessed via conventional 2D echo parameters or cardiac magnetic resonance [CMR]) occurs in 25% of patients with severe AS . Studies assessing RV size and function by echocardiography found that larger basal‐ and mid‐RV diameter, but not RV dysfunction (assessed by TAPSE or fractional area change), were independently associated with increased mortality .…”

“…3 Despite the peak transvalvular gradient is frequently obtained using the simplified Bernoulli equation (ie, ΔP=4V 2 AO ), it should be correctlycomputedusingthecompleteBernoulliequation where ΔP is the peak gradient, V AO isthepeaktransprostheticvelocity measuredwithcontinuous-wave(CW)Doppler;andV LVOT is the veloc- In contrast, RV ejection fraction ≤50%, but not the end-systolic or end-diastolic volumes, by CMR was independently associated with impaired survival (HR=2.12, P=.017) of patients who underwent TAVR. 43 Furthermore,whenevaluatedbyCMRor3Dechocardiography,RVfunctionwasreportedtoremainunchangedafterTAVR, 45,46 incomparisonwithreducedRVejectionfractionaftersurgicalvalve replacement. 45 Pulmonary hypertension is an independent risk factor associ-atedwithtwotimeshighermortalityrateafterTAVR.…”