The Effect of TAVR on Left Ventricular and Left Atrial Mechanics in Patients with Aortic Stenosis

Abstract

Background. Measures of adverse cardiac remodeling, left ventricular global longitudinal strain (LVGLS) and left atrial (LA) phasic function, are predictive of cardiac events in patients with severe aortic stenosis (AS). How these parameters of cardiac function change following TAVR requires further investigation. Methods. A number of 109 consecutive patients with symptomatic severe AS who were seen in the heart valve clinic between 2014 and 2019 for TAVR were included. All patients underwent echocardiographic assessment prior to and 30 days following TAVR, with LVGLS and LA phasic function evaluation using 2D speckle-tracking echocardiography. Heart failure hospitalization, and death were assessed at 12 months. Results. The mean age of the study cohort was 81 ± 7.3 years. Following TAVR, there was a significant reduction in NYHA class III/IV symptoms [89 (82%) vs. 12 (11%), p < 0.01], and median mean aortic valve gradient [44 mmHg (16) vs. 9 mmHg (7), p < 0.01]. There was no significant change in the median LVEF [62% (13) vs. 62% (6.0), p = 0.2]; however, the LVGLS significantly increased following TAVR [15 ± 3.5% vs. 18 ± 3.3%, p < 0.01]. The median LA reservoir, conduit and contractile function significantly improved following TAVR [22.0% (14.0) vs. 18.0% (14.0) p < 0.01, 8.9% (5.4) vs. 7.8% (4.8) p < 0.01, 12% (11.0) vs. 9.6% (11.0) p < 0.01, respectively]. The incidence of death or heart failure hospitalization at 12 months was low, and occurred in eight patients (7.3%). Conclusions. TAVR results in significant short-term reverse LV and LA remodeling, as shown by improvement in LV GLS and all three components of LA phasic function, despite no change in the LVEF. The findings indicate the possible utility of strain imaging for the assessment of global LV and LA function following TAVR.

The use of deformation imaging in the assessment of patients pre and post transcatheter aortic valve implantation

“…Similarly Cimino et al demonstrated acute changes in GLS following TAVI five days post procedure, examining separate layers of the myocardium showing significant improvements in endocardial layer LS in those with concentric LVH compared to those with eccentric hypertrophy [ 12 ]. Equivalently, in a US population of 109 patients, thirty days post TAVI there was significant short-term reverse LV and LA remodelling, with improvements in LV GLS and all three components of LA phasic function, without any recovery of ejection fraction [ 13 ]. Early improvements in GLS were also shown in a United Kingdom TAVI population over a mean follow-up period of 49 days and corresponding with previous studies this was without any change in LVEF [ 14 ].…”

Atrial Cardiomyopathy in Valvular Heart Disease: From Molecular Biology to Clinical Perspectives

“…These patients had a better improvement in clinical status and lower rates of major adverse cardiac events at one-year follow up, than patients with unchanged left atrial size [ 138 ]. The vast majority of literature reported an improvement in left atrial reservoir function following aortic valve replacement [ 139 , 140 , 141 , 142 , 143 , 144 ]. Interestingly, most studies did not exclude confounding factors of atrial strain assessment, such as atrial fibrillation and/or moderate-severe mitral valve disease [ 139 , 142 , 143 , 145 ].…”

“…The vast majority of literature reported an improvement in left atrial reservoir function following aortic valve replacement [ 139 , 140 , 141 , 142 , 143 , 144 ]. Interestingly, most studies did not exclude confounding factors of atrial strain assessment, such as atrial fibrillation and/or moderate-severe mitral valve disease [ 139 , 142 , 143 , 145 ]. Weber et al reported that left atrial reservoir function and volume, in addition to left ventricular function, were associated with worse outcomes after TAVR [ 141 ].…”

“…The study group showed that the lack of improvement in left atrial reservoir strain after TAVR was associated with a worse outcome [ 122 ]. Left atrial contraction strain was less frequently examined in the studies, but most studies found an improvement in left atrial contraction function [ 139 , 140 , 144 , 146 ]. The incidence of postoperative atrial arrhythmias requiring treatment after aortic valve replacement was 48.8%.…”