Reverse left atrium and left ventricle remodeling after aortic valve interventions

Transcription

1 Reverse left atrium and left ventricle remodeling after aortic valve interventions Alexandra Gonçalves, Cristina Gavina, Carlos Almeria, Pedro Marcos-Alberca, Gisela Feltes, Rosanna Hernández-Antolín, Enrique Rodríguez, Adelino Leite-Moreira, JC. Silva Cardoso, Carlos Macaya, José Zamorano No disclosures

2 Background Calcific aortic stenosis (AS) is a common disorder in elderly patients and is associated with left ventricular (LV) hypertrophy, LV dysfunction and adverse clinical outcomes. Heart Fail Clin 2006; 2 (4): Surgical aortic valve replacement (AVR) is the definitive proven therapy for patients with severe AS who have symptoms or LV dysfunction. Eur Heart J 2007; 28: Circulation 2008;118:e AVR dramatically reduces LV pressure overload, determining a marked LV mass decrease and a LV systolic and diastolic function improvement Am J Cardiol, 2002; 89: J Heart Valve Dis, 2000; 9: Heart, 2001; 86:

3 Background Recently, transcatheter aortic valve implantation (TAVI) has emerged as a viable treatment option for patients with symptomatic severe AS who are at very high risk for operative mortality. There have been several reports of good midterm hemodynamic results, showing low transprosthetic gradients and large prosthetic valve effective oriffice area (EOA) after TAVI. Am Heart J 2010;159: J Am Soc Echocardiogr 2011;24:28-36

4 Objective We aimed to compare reverse remodeling in patients with severe aortic stenosis referred to TAVI or AVR at 6 months after the procedure.

5 Methods 129 consecutive patients 60 years old with severe aortic stenosis and symptoms or LV dysfunction, selected from two prospective cohorts (H. S. João Porto; H. Clínico San Carlos Madrid) 72 (55.8%) submitted to TAVI and 57 (44.2%) to AVR Clinical evaluation and 2D and 3D transthoracic echocardiography (TTE) at baseline and 6 months follow-up Echocardiography data: 2D TTE variables were calculated according to the American Society of Echocardiography recommendations LV mass was calculated by 3D guided biplane analysis, LV and LA volumes were calculated by 3D direct volumetric analysis. Statistical analysis: Categorical variables were compared using χ2 tests. Continuous variables are presented as mean ± SD. Two-tailed unpaired Student s t tests were used for comparisons between groups, and paired Student s t tests were used for intragroup comparisons. A P value <.05 was considered statistically significant.

6 Methods Aortic Valve Replacement (AVR) Cohort All patients had severe aortic valve stenosis (aortic valve area 1 cm2) and were symptomatic or had LV dysfunction. No planned simultaneous coronary revascularization (< 50% lesions in coronariography) AVR with standard median sternotomy under cardiopulmonary bypass. The size of the valve was determined by the diameter of the aortic annulus as measured by precalibrated cylindrical sizers and proprietary valve size Type of prosthesis: 78,9% stented bioprostheses Size 21 mm in 54.4% and 23 mm in 26.3%

7 Methods Transcatheter aortic valve implantation (TAVI) Cohort All patients had severe aortic valve stenosis (aortic valve area 1 cm2) and were ineligible for conventional aortic valve replacement (AVR) Pre-procedure assessment included medical history, physical examination, trans-thoracic and TEE, coronary angiography, aortography, iliac-femoral arteriography and when necessary, CT scan. The procedure was performed under fluoroscopy and TEE guidance Type of prosthesis: Percutaneous approach n=49; Transapical approach n=23 Edward Sapien n= 51 (size 23 n=24; size 26 n=27); CoreValve n=21(size 26 n=19; size 29 n=2)

8 Results Clinical characteristics TAVI (n=72) AVR (n=57) p Value Age, yrs 81.9 ± ± 6.6 < Female, n (%) 39 (54.2%) 34 (59.6%) 0.65 Hypertension, n (%) Diabetes mellitus, n (%) Coronary artery disease, n (%) <0.001 COPD, n (%) Renal Impairment Peripheral vascular disease <0.001 NYHA class <0.001 EF < 50%

9 Baseline Ecocardiography TAVI AVR P Value Ao annulus diameter (mm) ± ± VE/Ao mean gradient (mmhg) ± ± Ao max. Velocity ± ± Aortic valve area/bsa(cm2/m2) 0.36 ± ± E/A 1.34 ± ± 0.33 <0.001 Deceleration time (ms) ± ± e (cm/s) 5.90 ± ± IVRT (ms) ± ± <0.001 E/e ± ± D LA volume/bsa (ml/m2) 46.3 ± ± D LVM/BSA (g/m2) ± ± D LVDV (ml) ± ± < D LVSV (ml) ± ± D LVEF (%) ± ±

10 6 months Ecocardiography TAVI AVR P Value transprosthesis mean gradient (mmhg) 8.1 ± ± <0.001 transprosthesis max. velocity ± ± <0.001 EOA/BSA(cm2/m2) 1.17 ± ± 0.26 <0.001 Severe PPM (%) E/A 1.19 ± ± Deceleration time (ms) ± ± e (cm/s) 6.65 ± ± IVRT (ms) ± ± E/e ± ± D LA volume/bsa (ml/m2) 41.4 ± ± D LVM/BSA (g/m2) ± ± D LVDV (ml) ± ± D LVSV (ml) ± ± D LVEF (%) ± ±

11 Aortic Regurgitation 6M FUP Aortic Regurgitation AVR TAVI P Value None 52/57 29/72 <0.001 Mild 5/57 35/72 Moderate 0 8/72 Severe 0 0

12 NYHA class 100% 80% 60% 40% 20% NYHA class class 4 class 3 class 2 class 1 0% Baseline 6M FUP Baseline 6M FUP p<0.001 AVR TAVI

13 3D LV volumes and EF NS p<0.001 p = NS p= NS Baseline 6 months FUP

14 3D LVM index 3D LV mass/bsa 3D LV mass/bsa (%) p=0.005 NS p=0.009 Baseline 6 months FUP

15 Parameters of diastolic function E/A ratio DT IVRT NS p=0.01 p=0.001 p=0.03 NS p<0.001 E E/E p=0.006 NS p=0.09 p=0.09 Baseline 6 months FUP

16 Parameters of diastolic function 3D LA Volume/BSA 3D LA Volume/BSA (%) p=0.029 NS p=0.15 Baseline 6 months FUP

17 Study limitations Nonrandomized study Reduced number of patients Baseline differences between groups TAVI pts had higher incidence of 6 months aortic regurgitation

18 Conclusions As expected, TAVI pts were older, had more hypertension, more comorbidities and were more symptomatic. At baseline TAVI pts had higher LA volume and higher LV diastolic filling pressures. Hemodynamic parameters after TAVI were superior to that after AVR in terms of transprosthetic gradients, EOAi, LV ejection fraction, and the prevention of severe PPM. There was a striking improvement of NYHA class in the TAVI group, better than that of the AVR group at 6 months.

19 Conclusions TAVI and AVR patients had similar improvement in LV diastolic filling pressures at 6 months, but LA volume had a significant decrease only in the TAVI group. LV reverse remodeling (decrease in LV volumes and LV mass) was only significant in AVR pts. The older age, presence of more comorbidities and long standing disease may have impaired LVH regression in TAVI pts.