1Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie Bad Krozingen, Deutschland; 2Institut für Medizinische Biometrie und Statistik Freiburg, Deutschland; 3Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie II Bad Krozingen, Deutschland; 4Universitäts-Herzzentrum Freiburg - Bad Krozingen Klinik für Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; 5Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland; 6Universitäts-Herzzentrum Freiburg / Bad Krozingen Bad Krozingen, Deutschland
Aim: The development of valvular cardiomyopathy (VCMP) with worsening systolic function in patients with aortic valve stenosis (AS) is thought to be a consequence of an increased afterload and myocardial remodelling. It is unclear, why some patients are more prone to develop VCMP than others and why it is reversible in only a part of patients after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the frequency and characteristics of VCMP in patients with severe AS and to identify predictors for its reversibility in order to single out patients that draw a larger benefit from TAVR.
Methods and results: Patients with severe AS that were treated with TAVR and had available echo data before and between day 1 and 31 after TAVR were included. Patients were categorized based on their left ventricular (LV) function into normal, mildly, moderately or severely impaired before and after TAVR. All included patients were followed up in order to assess the endpoints of all-cause mortality, stroke, bleeding complications and rehospitalization at 3 years. Cox regression analyses were performed to identify potential predictors of an improvement of LV function after TAVR.
3635 patients with available echo data before and after TAVR were included in the analysis. The median age was 83.0 [IQR 79.0, 86.0], 53.9% were female, 60.3% had known coronary artery disease (CAD) and 13.6% had a history of myocardial infarction. The majority (67.0%) of all included patients had a normal LV function before TAVR, but 589 (16.2%), 390 (10.7%) and 219 (6%) had a mildly, moderately or severely impaired LV function before TAVR, respectively. 659 (52.7%) of patients with an impaired LV function before TAVR showed an improvement thereof after the intervention. Patients with an improvement of their LV function after TAVR had a significantly better outcome regarding all-cause mortality compared to patients without a recovery of LV function (hazard ratio (HR) 1.3, 95% confidence interval (CI) 1.1-1.53, p=0.002). However, regarding the composite endpoint there was not a significant difference between the two groups. Significant predictors for a recovery of VCMP after TAVR were a smaller LV end diastolic diameter (LVEDD) (odds ratio (OR) 0.93, CI 0.90-0.96, p<0.001), a higher mean gradient of the aortic valve before TAVR (OR 1.03, CI 1.02-1.05, p<0.001) and a severely impaired LV function before TAVR (OR 4.33, CI 2.51-7.63, p<0.001). Age, sex, a history of CAD, chronic kidney disease, the type of the implanted valve, the grade of paravalvular regurgitation post TAVR or concomitant disorders of the mitral or tricuspid valve were not associated with a change of LV function after TAVR.
Conclusions: In this real-world cohort, approximately a third (32.9%) of patients with severe AS presented with an impaired LV function before TAVR and more than half of these patients (52.7%) showed an improvement thereof after the intervention. A severely impaired LV function, smaller LVEDD and higher mean gradient of the AS pre-TAVR were identified as predictors for a potential recovery from VCMP.