Early hemodynamic changes after transcatheter aortic valve implantation in patients with severe aortic stenosis measured by invasive pressure volume loop analysis

Abstract

Replacement of a stenotic aortic valve reduces immediately the ventricular to aortic gradient and is expected to improve diastolic and systolic left ventricular function over the long term. However, the hemodynamic changes immediately after valve implantation are so far poorly understood. Within this pilot study, we performed an invasive pressure volume loop analysis to describe the early hemodynamic changes after transcatheter aortic valve implantation (TAVI) with self-expandable prostheses. Invasive left ventricular pressure volume loop analysis was performed in 8 patients with aortic stenosis (mean 81.3 years) prior and immediately after transfemoral TAVI with a self-expandable valve system (St. Jude Medical Portico Valve). Parameters for global hemodynamics, afterload, contractility and the interaction of the cardiovascular system were analyzed. Left ventricular ejection fraction, (53.9% vs. 44.8%, p = 0.018), preload recruitable stroke work (68.5 vs. 44.8 mmHg, p = 0.012) and end-systolic elastance (3.55 vs. 2.17, p = 0.036) both marker for myocardial contractility declined significantly compared to baseline. As sign of impaired diastolic function, TAU, a preload-independent measure of isovolumic relaxation (37.3 vs. 41.8 ms, p = 0.018) and end-diastolic pressure (13.1 vs. 16.4 mmHg, p = 0.015) raised after valve implantation. Contrarily, a smaller ratio of end-systolic to arterial elastance (ventricular-arterial coupling) indicates an improvement of global cardiovascular energy efficiency (1.40 vs. 0.97 p = 0.036). Arterial elastance had a strong correlation with the number of conducted rapid ventricular pacings (Pearson correlation coefficient, r = 0.772, p = 0.025). Invasive left ventricular pressure volume loop analysis revealed impaired systolic and diastolic function in the early phase after TAVI with self-expandable valve for the treatment of severe aortic stenosis. Contrarily, we found indications for early improvement of global cardiovascular energy efficiency.

Acute haemodynamic impact of transcatheter aortic valve implantation in patients with severe aortic stenosis

“…negative dP/dT). Our results are in line with the recent findings of Seppelt et al 16 . They performed (in a pilot study on eight patients) an invasive LV pressure volume loop analysis and found impaired systolic and diastolic function in the early phase after TAVI, even if ventricular–arterial coupling data suggested an early improvement of global cardiovascular energy efficiency.…”

“…Despite several studies aiming to compare non‐invasive (echocardiographic and cardiac magnetic resonance) pre‐TAVI and post‐TAVI data have been performed, poor data are available on the role of the haemodynamic assessment performed immediately before and after prosthesis deployment in patients with severe AS 15,16,35,36 …”

“…There are limited data regarding the invasive haemodynamic evaluation of patients undergoing TAVI and even less about the prognostic role of the haemodynamic study performed immediately before and after prosthesis deployment 15–20 . Most of the available invasive studies focused on right heart catheterization, 17–20 and the few studies performed with left heart catheterization (LHC) focused on the role of residual aortic regurgitation (AR) as predictor of long‐term mortality 21,22 …”

Cardiac Structural Remodeling and Hemodynamic Patterns Following Transcatheter Aortic Valve Replacement

“…Despite a significant improvement in LV mass index, hemodynamic changes demonstrated a nonstatistically significant trend towards improved LVOT stroke volume, stroke volume index, cardiac output, and cardiac index on follow-up echocardiograms, similar to prior studies [16]. Comparably, we did not observe an anticipated significant change in ejection fraction post-TAVR.…”

“…Once deployed, it is expected for the TAVR to reduce myocardial contractility and impair diastolic function, followed by an improvement in ejection fraction after 30 days. This phenomenon is thought to be secondary to temporary myocardial stunning provoked by rapid ventricular pacing during TAVR [ 16 ].…”