Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement

Abstract

Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.

Comparative Analysis of Left Ventricular Mass Regression Following Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement – a Single Center Experience from Romania

“…Finally, the road ahead is paved with opportunities for improving patient post-TAVI outcomes (23). From early interventions in asymptomatic aortic stenosis to individualized management of comorbidities, a holistic approach is likely to yield the best results (16).…”

Reverse left ventricular remodeling after aortic valve replacement for aortic stenosis: a systematic review and meta-analysis

“…Clinically, this process can translate into various symptoms, including death due to heart failure or arrhythmic events ( 2 ). In other words, maladaptive LV response negatively impacts the prognosis of AS patients regarding survival and cardiovascular events ( 3 ).…”