https://doi.org/10.1007/s00392-025-02625-4
1Klinikum rechts der Isar der Technischen Universität München Klinik und Poliklinik für Innere Medizin I München, Deutschland; 2Deutsches Herzzentrum München Klinik für Herz- und Kreislauferkrankungen München, Deutschland; 3Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; 4Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie und internistische Intensivmedizin Kiel, Deutschland
Background: Aortic stenosis is a common valve disease in elderly individuals. Transcatheter aortic valve replacement (TAVR) has expanded treatment options, especially for elderly patients with multiple health conditions, though not all patients experience improved outcomes from TAVR. Aortic stenosis creates sustained pressure overload in the left ventricle, leading to hypertrophic remodeling of the heart. This remodeling contributes to secondary myocardial damage, including cardiomyocyte loss and fibrosis, as the left ventricular mass increases. These changes in left ventricular dimensions can be observed using echocardiography. To examine potential impacts on procedural and long-term outcomes following TAVR, various echocardiographic patterns of left ventricular hypertrophy were analyzed within four patient subgroups.
Methods: The study included 1,483 patients with severe aortic stenosis who underwent TAVR between January 2014 and August 2022 at two TAVR centers in Munich and Kiel. Patients were categorized into four groups based on left ventricular mass index (LVMI) and relative wall thickness (RWT): normal geometry (N; n=57), concentric remodeling (RWT > 0.42; LVMI ≤ 95 g/m² for women and ≤ 115 g/m² for men) (CR; n=276), concentric hypertrophy (CH; n=981), and eccentric hypertrophy (EH; n=169). Retrospective analysis of patient data was conducted to assess clinical outcomes, with specific attention to comparisons between the concentric and eccentric hypertrophy subgroups.
Results: Statistically significant differences were observed in left ventricular ejection fraction, logistic EuroSCORE I, and incidence of previous myocardial infarction as well as aortic and mitral valve insufficiency, with particular emphasis on the eccentric hypertrophy group. Mortality rates at one and four years were highest in the eccentric hypertrophy group, while the 30-day all-cause mortality differed significantly between the N and CR group. Figure 1 illustrates mid-term survival rates up to five years, comparing outcomes across all four groups.
Figure 1. Mid-term survival after TAVR; Kaplan-Meier estimates of the survival function after TAVR in the 4 groups determined by hypertrophy (Log-Rank <0.001).
A multivariate Cox regression was performed based on the significant results in the previously performed univariate regression. An association between all-cause mortality and age, atrial fibrillation and ejection fraction was observed (p=0.001) (Table 1).
Table 1. Multivariate analysis of the significant influencing factors observed in the univariate regression.
Conclusion: Most patients undergoing TAVR showed a pattern of concentric hypertrophy. Compared to the other groups, the EH group had the poorest outcomes at both 1-year and mid-term follow-ups, followed by the CR and CH groups. The best outcomes were observed in patients with a normal left ventricular pattern prior to TAVR. These findings suggest that the high-risk EH group may benefit from further investigation to identify additional predictors of adverse outcomes and could benefit from closer monitoring during follow-up.