Reversibility of Cardiac Function Predicts Outcome After Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis

Kimi Sato, Arnav Kumar, Brandon M Jones, Stephanie L Mick, Amar Krishnaswamy, Richard A Grimm, Milind Y Desai, Brian P Griffin, L Leonardo Rodriguez, Samir R Kapadia, Nancy A Obuchowski, Zoran B Popović, Kimi Sato, Arnav Kumar, Brandon M Jones, Stephanie L Mick, Amar Krishnaswamy, Richard A Grimm, Milind Y Desai, Brian P Griffin, L Leonardo Rodriguez, Samir R Kapadia, Nancy A Obuchowski, Zoran B Popović

Abstract

Background: Reversibility of left ventricular (LV) dysfunction in high-risk aortic stenosis patient and its impact on survival after transcatheter aortic valve replacement (TAVR) are unclear. We aimed to evaluate longitudinal changes of LV structure and function after TAVR and their impact on survival.

Methods and results: We studied 209 patients with aortic stenosis who underwent TAVR from May 2006 to December 2012. Echocardiograms were used to calculate LV end-diastolic volume index (LVEDVi), LV ejection fraction, LV mass index (LVMi), and global longitudinal strain before, immediately (<10 days), late (1-3 months), and yearly after TAVR. During a median follow-up of 1345 days, 118 patients died, with 26 dying within 1 year. Global longitudinal strain, LVEDVi, LV ejection fraction, and LVMi improved during follow-up. In patients who died during the first year, death was preceded by LVEDVi and LVMi increase. Multivariable longitudinal data analysis showed that aortic regurgitation at baseline, aortic regurgitation at 30 days, and initial LVEDVi were independent predictors of subsequent LVEDVi. In a joint analysis of longitudinal and survival data, baseline Society of Thoracic Surgeons score was predictive of survival, with no additive effect of longitudinal changes in LVEDVi, LVMi, global longitudinal strain, or LV ejection fraction. Presence of aortic regurgitation at 1 month after TAVR was the only predictor of 1-year survival.

Conclusions: LV reverse remodeling was observed after TAVR, whereas lack of LVEDVi and LVMi improvement was observed in patients who died during the first year after TAVR. Post-TAVR, aortic regurgitation blocks reverse remodeling and is associated with poor 1-year survival after TAVR.

Keywords: aortic valve stenosis; echocardiography; longitudinal strain; remodeling; transcatheter aortic valve implantation.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Changes of (A) GLS and LVEF and (B) LVEDVi and LVMi. Markers represent the average of the observed data obtained before TAVR (time zero) over the intervals of 0 to 100, 101 to 300, 301 to 600, 601 to 1000, 1001 to 1300, and >1300 days. Error bars represent 95% CIs. The regression line is obtained by the mixed‐model approach. In GLS and LVEF, immediate change and late change were analyzed separately. P values for time after TAVR are shown. GLS indicates global longitudinal strain; LVEDVi, left ventricular end‐diastolic volume index; LVEF, left ventricular ejection fraction; LVMi, left ventricular mass index; TAVR, transcatheter aortic valve replacement.
Figure 2
Figure 2
Changes of (A) LVEDVi and (B) delta change of LVEDVi when we stratified patients according to postprocedural aortic regurgitation severity at 1 month after TAVR. Patients with postprocedural aortic regurgitation detected during the first 30 days after TAVR had higher initial LVEDVi. They did not show decrease in LVEDVi during long‐term follow‐up. Markers represent the average of the observed data obtained before TAVR (time zero) over the intervals of 0 to 100, 101 to 300, 301 to 600, 601 to 1000, 1001 to 1300, and >1300 days. Error bars represent 95% CIs. Delta change of LVEDVi was calculated by subtracting follow‐up data by baseline value (negative value means improvement in LVEDVi). AR indicates aortic regurgitation; LVEDVI, left ventricular end‐diastolic volume index; TAVR, transcatheter aortic valve replacement.
Figure 3
Figure 3
Changes of (A) LVEDVi and (B) LVMi when we stratified patients according to 1‐year mortality. Markers represent the average of the observed data obtained before TAVR (time zero) over the intervals of 0 to 30, 31 to 100, 101 to 400, 401 to 900, 901 to 1300, and >1300 days. Error bars represent 95% CIs. The regression line is obtained by the mixed‐model approach. The model was constructed with patients’ groups, change over time, and interaction between groups and change (showing if magnitude of changes are different between groups). Significant P values for comparison between groups, change over time, and interaction between group and change (Group×change over time) are shown. GLS indicates global longitudinal strain; LVEF, left ventricular ejection fraction; LVEDVi, left ventricular end‐diastolic volume index; LVMi, left ventricular mass index.
Figure 4
Figure 4
Comparison of changes of (A) GLS, (B) LVEF, (C) LVEDVi, and (D) LVMi in present study with previous studies. Markers (black circle) represent the average of the observed data obtained each time point as described in Figure 1. The solid line showed regression line which was obtained by a mixed‐model approach in the present study, and the dashed line shows 95% CIs of regression line. Average of the reported values in previous studies at baseline and follow‐up are also plotted. GLS indicates global longitudinal strain; LVEDVi, left ventricular end‐diastolic volume index; LVEF, left ventricular ejection fraction; LVMi, left ventricular mass index; TAVR, transcatheter aortic valve replacement.

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