Echocardiographic Assessment of Diastolic Dysfunction in Elderly Patients with Severe Aortic Stenosis Before and After Aortic Valve Replacement

Abstract

Background: The 2016 guidelines of the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) for evaluation of left ventricular (LV) diastolic dysfunction by Doppler flow and tissue Doppler- echocardiography do not adjust assessment of high filling pressures for patients with aortic stenosis (AS). However, most of the studies on this patient group indicate age independent specific diastolic features in AS. The aim of this study is to identify disease-specific range and distribution of diastolic functional parameters and their ability to identify high N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels as a marker for high filling pressures.Methods: In this study, 169 patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Resting echocardiography was performed including Doppler of the mitral inflow, pulmonary venous flow, tricuspid regurgitant flow and tissue Doppler in the mitral ring and indexed volume-estimates of the left atrium (LAVI). Echocardiography, and NT-proBNP levels were assessed before TAVR/SAVR and at two postoperative visits at 6 and 12 months. Results: Pre- and postoperative values were septal e´; 5.1±3.9, 5.2±1.6 cm/s; lateral e´ 6.3±2.1; 7.7±2.7 cm/s; E/e´19±8; 16±7 cm/s; E velocity 96±32; 95±32 cm/s; LAVI 39±8; 36±8 ml/m2, pulmonary artery pressure (PAP) 39±8; 36±8 mmHg, respectively. The scoring recommended by ASE/EACVI detected elevated NT pro-BNP with a specificity of 25%. Adjusting thresholds towards PAP ≥ 40 mmHg, E velocity ≥ 100 cm/s, E deceleration time < 220 ms, and E/septal e´ ≥ 20 or septal e´< 5.0 cm/s increased prediction of NT-proBNP levels ≥ 500 ng/L with substantially increased specificity (>85%).Conclusion: Diastolic echocardiographic parameters in AS indicate persistent impaired relaxation and NT-proBNP indicate elevated filling pressures in most of the patients, improving only modestly 6-12 months after TAVR and SAVR. Applying the 2016 ASE/EACVI recommendations for detection of elevated filling pressures to patients with AS, elevated NT pro-BNP levels could not be reliably detected. However, adjusting thresholds of the echocardiographic parameters increased specificities to useful diagnostic levels. Trial registration: The study was prospectively approved by the regional ethical committee, REK North with the registration number: REK 2010/397-10

Left and right ventricular functional changes after transapical, transfemoral, transcatheter, or surgical aortic valve replacement: A single-center observational study

“…As previously described in the same AS population (30), diastolic dysfunction consists of both impaired relaxation and increased end-diastolic pressure due to increased ventricular and atrial filling and myocardial stiffness following fibrosis. Signs of increased stiffness due to high filling pressures are expected to reverse as a result of afterload reduction (31), whereas stiff myocardium due to macro-or micro-scarring is expected to render irreversibly high filling pressures (32).…”

Hemodynamics and Diastolic Function after Native Aortic Valve Preserving vs. Replacing Surgery

“…Tricuspid regurgitation systolic jet velocity was not assessed systematically as concomitant tricuspid regurgitation was recorded only in very few patients. Early to late diastolic transmitral flow velocity ratio (E/A) was also not assessed as this ratio is known to be elevated in younger patients without clinical significance [15,16] and is only part of the algorithm to predict LV diastolic function in patients with depressed LV ejection fraction [17,18]. In most of our patients, however, LV systolic function was preserved pre-and postoperatively.…”