Beyond Pressure Gradients: The Effects of Intervention on Heart Power in Aortic Coarctation

Joao Filipe Fernandes, Leonid Goubergrits, Jan Brüning, Florian Hellmeier, Sarah Nordmeyer, Tiago Ferreira da Silva, Stephan Schubert, Felix Berger, Titus Kuehne, Marcus Kelm, CARDIOPROOF Consortium, Joao Filipe Fernandes, Leonid Goubergrits, Jan Brüning, Florian Hellmeier, Sarah Nordmeyer, Tiago Ferreira da Silva, Stephan Schubert, Felix Berger, Titus Kuehne, Marcus Kelm, CARDIOPROOF Consortium

Abstract

Background: In aortic coarctation, current guidelines recommend reducing pressure gradients that exceed given thresholds. From a physiological standpoint this should ideally improve the energy expenditure of the heart and thus prevent long term organ damage.

Objectives: The aim was to assess the effects of interventional treatment on external and internal heart power (EHP, IHP) in patients with aortic coarctation and to explore the correlation of these parameters to pressure gradients obtained from heart catheterization.

Methods: In a collective of 52 patients with aortic coarctation 25 patients received stenting and/or balloon angioplasty, and 20 patients underwent MRI before and after an interventional treatment procedure. EHP and IHP were computed based on catheterization and MRI measurements. Along with the power efficiency these were combined in a cardiac energy profile.

Results: By intervention, the catheter gradient was significantly reduced from 21.8±9.4 to 6.2±6.1mmHg (p<0.001). IHP was significantly reduced after intervention, from 8.03±5.2 to 4.37±2.13W (p < 0.001). EHP was 1.1±0.3 W before and 1.0±0.3W after intervention, p = 0.044. In patients initially presenting with IHP above 5W intervention resulted in a significant reduction in IHP from 10.99±4.74 W to 4.94±2.45W (p<0.001), and a subsequent increase in power efficiency from 14 to 26% (p = 0.005). No significant changes in IHP, EHP or power efficiency were observed in patients initially presenting with IHP < 5W.

Conclusion: It was demonstrated that interventional treatment of coarctation resulted in a decrease in IHP. Pressure gradients, as the most widespread clinical parameters in coarctation, did not show any correlation to changes in EHP or IHP. This raises the question of whether they should be the main focus in coarctation interventions. Only patients with high IHP of above 5W showed improvement in IHP and power efficiency after the treatment procedure.

Trial registration: clinicaltrials.gov NCT02591940.

Conflict of interest statement

The authors have no competing interests to declare.

Figures

Fig 1. Study flow diagram.
Fig 1. Study flow diagram.
Flow of participants through the study.
Fig 2. The assessment of a cardiac…
Fig 2. The assessment of a cardiac energy profile in patients with aortic coarctation.
In all evaluated study participants this profile was acquired before and after the interventional treatment procedure. AV Aortic valve, CoA coarctation of the aorta, EHP External heart power, Ea arterial load, Emax the slope of the end-systolic pressure-volume relationship, IHP Internal heart power. LV Left ventricle, PV-loops Pressure-Volume loops.
Fig 3. Main results.
Fig 3. Main results.
(a) Internal heart power (IHP) before and after treatment divided into groups according to the initial IHP above and below 5 W (b) The change in IHP with treatment plotted against the change of catheter-measured pressure gradients in each patient (the start-point of each vector represents the state before treatment, whereas the end-point represents the state after treatment) (c) Power efficiency before and after treatment grouped according to the initial IHP. * statistically significant differences.

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