Diastolic Dysfunction Should Be Considered in TAVR

Aortic stenosis increases afterload creating hypertrophy as a compensation mechanism to maintain minute volume. This leads to left ventricular diastolic dysfunction (LVDD).

More than half of patients presenting aortic stenosis have LVDD and myocardial fibrosis, which is a mortality predictor in surgery.

At present, there is contradicting evidence in TAVR.

The study looked into 777 consecutive patients undergoing TAVR. 545 (70%) presented LVDD: grade I, 98 (18%); grade II, 198 (36.3%); and grade III, 104 (19.1%). 145 patients (26.6%) were excluded for LVDD grade discrepancies.

Read also: Delayed Coronary Obstruction After TAVR: A Complication We Had Not Considered.

Even though populations were similar, patients presenting LVDD were mostly men and had more history of prior AMI and CABG. The higher the LVDD grade, the higher the risk score, with more symptoms and increased BNP.

There were no differences in aortic valve area, but there was lower ejection fraction in those presenting LVDD, more concomitant mitral or tricuspid regurgitation and altered ventricular geometry because of associated eccentric hypertrophy.

At one year, all-cause mortality was higher in patients with LVDD, which was twice as high in patients presenting grade I; 2.5 times higher in grade II patients and 4 times higher in grade III patients. This last group also saw higher mortality at 30 days.

Read also: Reverse Myocardial Remodeling Following Valve Replacement.

Mortality was driven by cardiac mortality. There were no differences in AMI or stroke. Mortality was not associated to ejection fraction, ventricular mass index, minute volume or the presence of major to mild leak.

Mortality predictors at one year were: LVDD (grades I, II, III), BMI ≤20 Kg/m², diabetes, COPD and peripheral vascular disease.

Conclusion

Advanced stages of LVDD after TVR are associated with increased risk of all-cause mortality driven by cardiovascular death, starting within the first 30 days.

Comment

The presence of LVDD is very frequent in low functional class patients with severe aortic stenosis. This is associated with a strong negative impact in the short term.

It might be necessary to treat these patients before they develop this condition, which would reduce mortality (especially cardiovascular). In fact, we might have to decide before symptoms appear in low functional class patients, or after eco-Doppler findings.

Courtesy of Dr. Carlos Fava.

Original title: The Impact of Left Ventricular Diastolic Dysfunction on Clinical After Trancatheter Aortic Valve Replacement

Reference: Masahiko Asami, et al. J Am Coll Cardiol Interv 2018;11:593-601

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