https://doi.org/10.1007/s00392-025-02737-x
1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; 2Universitätsklinikum Würzburg Deutsches Zentrum für Herzinsuffizienz Würzburg, Deutschland; 3Klinikum Oldenburg AöR Klinik für Kardiologie Oldenburg, Deutschland; 4Universitätsklinikum des Saarlandes Institut für Rechtsmedizin Homburg/Saar, Deutschland; 5Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; 6University Leiden Department of Cardiology Leiden, Niederlande
Background:
In aortic stenosis (AS), chronic pressure overload of the left ventricle (LV) may sustain an intrinsic, afterload-dependent adaptive response known as the Anrep effect, characterized by increased myocardial contractility and prolonged systolic duration. Whether this response resolves following transcatheter aortic valve implantation (TAVI) remains unknown.
Objective:
This study investigated whether a chronic Anrep effect operates in severe (high-grade) aortic valve stenosis and whether it reverses following TAVI, which could provide marked afterload reduction.
Methods:
We examined 119 patients with high-gradient AS who underwent TAVI implantation. Echocardiography was used to estimate pressure–volume (PV) loops both before and 24 hours after the procedure as well as left ventricular ejection fraction (LVEF).
The “Anrep Triad,” characterized by increased afterload (left ventricular end-systolic pressure [LVESP] and effective arterial elastance [Ea]), improved contractility (end-systolic elastance [Ees] and end-systolic volume at 150 mmHg [ESV150]) and extended systolic ejection time (SET) were evaluated. Left ventricular energetics were measured using stroke work (SW), potential energy (PE), pressure–volume area (PVA) and mechanical efficiency (SW/PVA).
Results:
TAVI significantly reduced afterload parameters, with LVESP decreasing from 220 to 143 mmHg and effective Ea from 2.8 to 2.0 mmHg/mL. Contractile function also declined, as indicated by reductions in Ees from 4.5 to 2.6 mmHg/mL and an increase in ESV150 from 39 to 53 mL. Concurrently, SET decreased from 390 to 321 ms (all p<0.0001).
Despite these changes, LVEF remained unchanged (56% pre- vs. post-TAVI, p=0.44).
Mechanical workload parameters showed a significant decline, with SW decreasing from 9017 to 6257 mmHg/mL and PVA from 14261 to 10017 mmHg/mL (p<0.0001). Mechanical efficiency, calculated as the ratio of SW to PVA, was preserved (64% vs. 63%, p=0.101).
Conclusion:
In patients with severe AS, the Anrep effect supports output at high energetic cost. TAVI reverses this condition by reducing the heart’s workload and mechanical demand without altering ejection fraction. These findings highlight the role of the Anrep effect in load-dependent mechanism in AS and demonstrates its reversibility post-TAVI.