Assessment of valve haemodynamics, reverse ventricular remodelling and myocardial fibrosis following transcatheter aortic valve implantation compared to surgical aortic valve replacement: a cardiovascular magnetic resonance study

Abstract

ObjectiveTo compare the effects of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) on aortic valve haemodynamics, ventricular reverse remodelling and myocardial fibrosis (MF) by cardiovascular magnetic resonance (CMR) imaging.DesignA 1.5 T CMR scan was performed preoperatively and 6 months postoperatively.SettingUniversity hospitals of Leeds and Leicester, UK.Patients50 (25 TAVI, 25 SAVR; age 77±8 years) high-risk severe symptomatic aortic stenosis (AS) patients.Main outcome measuresValve haemodynamics, ventricular volumes, ejection fraction (EF), mass and MF.ResultsPatients were matched for gender and AS severity but not for age (80±6 vs 73±7 years, p=0.001) or EuroSCORE (22±14 vs 7±3, p<0.001). Aortic valve mean pressure gradient decreased to a greater degree post-TAVI compared to SAVR (21±8 mm Hg vs 35±13 mm Hg, p=0.017). Aortic regurgitation reduced by 8% in both groups, only reaching statistical significance for TAVI (p=0.003). TAVI and SAVR improved (p<0.05) left ventricular (LV) end-systolic volumes (46±18 ml/m2 vs 41±17 ml/m2; 44±22 ml/m2 vs32±6 ml/m2) and mass (83±20 g/m2 vs 65±15 g/m2; 74±11 g/m2 vs 59±8 g/m2). SAVR reduced end-diastolic volumes (92±19 ml/m2 vs 74±12 ml/m2, p<0.001) and TAVI increased EF (52±12% vs 56±10%, p=0.01). MF reduced post-TAVI (10.9±6% vs 8.5±5%, p=0.03) but not post-SAVR (4.2±2% vs 4.1±2%, p=0.98). Myocardial scar (p≤0.01) and baseline ventricular volumes (p<0.001) were the major predictors of reverse remodelling.ConclusionsTAVI was comparable to SAVR at LV reverse remodelling and superior at reducing the valvular pressure gradient and MF. Future work should assess the prognostic importance of reverse remodelling and fibrosis post-TAVI to aid patient selection.

Sex-related differences in left ventricular remodeling in severe aortic stenosis and reverse remodeling after aortic valve replacement: A cardiovascular magnetic resonance study

“…It is possible that the MF regression is different according to sex, with the more varied distribution n early tendency to regress.. It is also possible that the regression in females is a reflection of the fact that more females underwent trans-catheter rather than surgical valve replacement, as it has previously been suggested that MF regression is seen following TAVR but not SAVR 15 . Failure of MF regression following AVR has been reported previously;…”

“…CMR imaging is the reference standard for LV mass and volume quantitation, with low intra-observer and inter-study variability. Moreover, sex-related differences in MF may play a key role in any reverse remodeling 15 . This can be accurately quantified non-invasively using the CMR late gadolinium enhancement (LGE) technique.…”

Acute Reverse Remodelling After Transcatheter Aortic Valve Implantation: A Link Between Myocardial Fibrosis and Left Ventricular Mass Regression

“…Details of the CMR pulse sequence have been previously published [3]. Briefly, CMR was performed pre-procedure (median 1 day, IQR 0 days) and prior to hospital discharge (median 4 days, IQR 1 day) using the same 1.5T scanner (Philips Healthcare, Best, The Netherlands).…”

“…Surgical aortic valve replacement (SAVR) and trans-catheter aortic valve implantation (TAVI) result in significant LV mass regression at medium and long term follow up [3,4], with TAVI having a superior mass reduction compared with SAVR at 6 months [3]. TAVI results in an immediate, greater improvement in aortic pressure gradient [5].…”

Almanac 2014: Cardiovascular Imaging.

“…Očekuje se da je jedna od odrednica prognoze AS-a fibroza miokarda koja nastaje uslijed dugoročnog preopterećenja pritiska. Fairbairn et al 45 pokazali su da se fibroza miokarda mjerena CMR-om smanjila u razdoblju od 6 mjeseci nakon podvrgnuća TAVI, iako nije primijećen nikakav učinak kod pacijenata koji su bili podvrgnuti kirurškoj zamjeni aortnog zalistka. 150 vessels of intermediate stenosis from 252 patients, FFRCT was better than CCTA for the diagnosis of lesion-specific ischaemia.…”