Systemic Vascular Load in Calcific Degenerative Aortic Valve Stenosis

Yotti, Raquel; Bermejo, Javier; Gutiérrez‐Ibañes, Enrique; Villar, Candelas Pérez del; Mombiela, Teresa; Elı́zaga, Jaime; Benito, Yolanda; González‐Mansilla, Ana; Barrio, Alicia; Rodríguez‐Pérez, Daniel; Martínez‐Legazpi, Pablo; Fernández-Avilés, Francisco

doi:10.1016/j.jacc.2014.10.067

Cited by 106 publications

(83 citation statements)

References 30 publications

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“…Collectively, the change from before TAVR to 30 days and 6 months after TAVR in each of these measures of arterial load was modest or absent although others have demonstrated acute increases in arterial load immediately after TAVR. 19 Arterial load parameters further stratified outcomes beyond SBP: patients with the worst outcomes had both a lower SBP and higher pulsatile arterial load.…”

Section: Discussionmentioning

confidence: 99%

“…17,18 However, focusing on valve hemodynamics alone may be inadequate as evidenced by a recent study showing increased vascular stiffness after transcatheter aortic valve replacement (TAVR). 19 Total vascular hydraulic load includes steady and pulsatile components. Steady load is represented by systemic vascular resistance, whereas pulsatile load is because of wave reflections and vascular stiffness.…”

mentioning

confidence: 99%

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Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis

Lindman

Otto

Douglas

et al. 2017

Circ: Cardiovascular Imaging

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A ortic stenosis (AS) has been conceptualized as a mechanical problem (valve obstruction) requiring a mechanical solution (valve replacement).1 It is often considered to be a disease of fixed left ventricular (LV) afterload because of an obstructed valve, with the theoretical concern that a decrease in vascular resistance due to vasodilator therapy could cause severe hypotension without the ability to augment stroke volume due to fixed obstruction at the valve level.2 Several recent studies show, however, that LV afterload in patients with AS functions like a series circuit, with important contributions from both the valve and vasculature. [3][4][5]

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis

Lindman

Otto

Douglas

et al. 2017

Circ: Cardiovascular Imaging

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“…In AS patients referred for valve replacement, a higher arterial stiffness correlates with less LV mass regression and with more adverse cardiac events after SAVR [26] and TAVI [27]. Yotti et al [4] studied arterial function before and after TAVI and reported an increase in arterial load after the procedure resulting in a residual elevation of LV pressure in 70% of patients. Moreover, myocardial response to AS involves variable degrees of myocardial fibrosis [28], the extent of which correlates with NYHA functional class at baseline [29], and predicts the improvement in NYHA class after valve replacement [29].…”

Section: Assessment Of Tavi Outcome: Patients' Vs Physicians' Perspementioning

confidence: 99%

Prevalence, Predictors and Prognostic Implications of Residual Impairment of Functional Capacity After Transcatheter Aortic Valve Implantation

Abdelghani

Cavalcante

Miyazaki

et al. 2017

Journal of the American College of Cardiology

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Background Patients with degenerative aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI) typically have advanced cardiac and vascular adverse remodeling and multiple comorbidities and, therefore, might not recover a normal functional capacity after valve replacement. We sought to investigate the prevalence, the predictors, and the prognostic impact of residual impairment of functional capacity after TAVI.

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“…[13][14][15] The deleterious effects of increased arterial stiffness and pulsatile load in this population are vastly underappreciated although likely not remediable with medical therapy in advanced age.…”

Section: See Article By Lindman Et Almentioning

confidence: 99%

Blood Pressure, Arterial Load, and Survival After Transcatheter Aortic Valve Replacement

O’Gara

2017

Circ: Cardiovascular Imaging

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Editorialby guest on May 11, 2018 http://circimaging.ahajournals.org/ Downloaded from 2 O'Gara BP, Arterial Load, and Survival After TAVR and greater longevity could have been confounded. 12 A single blood pressure determination in elderly patients 30 days after TAVR may not provide enough information from which to draw firm conclusions on causality.The current study's observations on the differential effects of total, pulsatile, and resistive arterial loads, and their interactions with SBP, are important reminders of the complex ventricular-valvular-arterial interactions that ensue in an elderly, predominantly hypertensive patient cohort after relief of aortic valve obstruction. [13][14][15] The deleterious effects of increased arterial stiffness and pulsatile load in this population are vastly underappreciated although likely not remediable with medical therapy in advanced age.Blood pressure management in patients with AS can be challenging for clinicians and patients. A reluctance to reduce preload or arterial resistance for fear of precipitating hypotension in the setting of a fixed cardiac output usually dominates the clinical picture despite the known long-term deleterious consequences of elevated impedances in series. Low diastolic blood pressure levels (<70 mm Hg) may be particularly hazardous in the context of reduced coronary flow reserve, especially under conditions of increased myocardial oxygen demand. High diastolic blood pressure levels (>90 mm Hg), on the contrary, are consistently associated with adverse outcomes across a range of cardiovascular conditions, including AS. 16 International practice guidelines recommend treatment for hypertension in patients with AS. 17,18 Data from the SEAS trial (Simvastatin and Ezetimibe in Aortic Stenosis) describe a J-shaped relationship between blood pressure and outcomes and suggest that a target blood pressure of 130 to 139/70 to 90 be considered for patients with asymptomatic mild-to-moderate AS. 16 The optimal range for systemic blood pressure in patients with severe AS, however, has not been established. The picture is further clouded by individual variation in dose-response relationships, polypharmacy, drug side effects, drug-drug interactions, and patient comorbidities.Lindman et al 8 have redrawn the clinician's attention to the evaluation and management of blood pressure in elderly, prohibitive-, or high-surgical risk patients after TAVR. Their findings suggest that lower SBP may be a marker for reduced survival in this cohort and may best be avoided if possible and as circumstances and drug choices allow. Other studies have shown that SBP increases in ≈50% of patients after TAVR possibly in relation to higher postprocedural stroke volume and cardiac output, 13 but more likely as a consequence of stiffer (less compliant) vascular behavior that is unmasked by the relief of the upstream valvular obstruction.14 Higher SBP may be a good thing, but apparently not when it is accompanied by signs of reduced vascular compliance. 8,14 Understanding the fac...

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Systemic Vascular Load in Calcific Degenerative Aortic Valve Stenosis

Abstract: Vascular function in calcific degenerative AS is conditioned by the upstream valvular obstruction that dampens forward and backward compression waves in the arterial tree. An increase in vascular load after TAVR limits the procedure's acute afterload relief.

Cited by 106 publications

References 30 publications

Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis

Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis

Prevalence, Predictors and Prognostic Implications of Residual Impairment of Functional Capacity After Transcatheter Aortic Valve Implantation

Blood Pressure, Arterial Load, and Survival After Transcatheter Aortic Valve Replacement

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