DOI DOI https://doi.org/10.1007/s00392-021-01843-w
Objectives
Nowadays aortic stenosis is one of the major valvular diseases in the western world. The transcatheter aortic valve replacement (TAVR) revolutionised the treatment options, which had been surgical aortic valve replacement (SAVR) and medical treatment before. Despite the promising results in comparison to SAVR, there are still patients who do not benefit from TAVR.
Aortic stenosis leads to hypertrophic cardiac remodeling as a sign of the cardiac adaption to chronic pressure overload. Myocyte degeneration, consecutive myocyte replacement and subsequently induced myocardial fibrosis occur due to the growing left ventricular (LV) mass. During this process different geometric changes of LV dimensions are measurable in echocardiography.
Different LV hypertrophy patterns in echocardiography were compared to identify a possible impact on periprocedural, 30-day, 1-year and mid-term outcome after TAVR.
Patients and methods
The study included 270 patients with severe aortic stenosis who received TAVR between 01/2015 and 08/2020. According to LV mass index (LVMI) and relative wall thickness (RWT) patients were divided into 4 groups: normal (n=16), concentric remodeling (RWT > 0.42; LVMI ≤ 95 g/m² for women and ≤ 115 g/m² for men) (CR; n=52), concentric hypertrophy (CH; n=169) and eccentric hypertrophy (EH; n=33). The data was analysed retrospectively and correlated to the clinical outcome.
Results
No significant differences exist between the groups in relation to pre-interventional aortic valve area and mean aortic gradient. Regarding the ejection fraction, mitral insufficiency ≥ °II, NYHA III/IV classification and logistic EuroSCORE I a statistically significant difference was calculated. There was no significant difference in the occurrence of coronary heart disease (CHD) in the 4 groups. The analysis showed no statistically significant difference in periprocedural complications except for occurrence of postprocedural myocardial infarction. There was a trend towards lower survival in the EH group after 30 days and 1 year (Figure 1). Figure 2 shows the mid-term survival up to 4 years.
Figure 1. 1-year survival after TAVR; Kaplan-Meier estimates of the survival function after TAVR in the 4 groups determined by hypertrophy.
Figure 2. Mid-term survival after TAVR; Kaplan-Meier estimates of the survival function after TAVR in the 4 groups determined by hypertrophy (log rank = 0.003).
Conclusion
Concentric hypertrophy is the most common hypertrophy pattern in pre-TAVR patients. Concerning the peri- and postprocedural complications, the occurrence of postprocedural myocardial infarction was the only statistically significant difference between the 4 hypertrophy groups in our study. The EH group had a poorer outcome after 30 days and 1 year. In the mid-term follow-up EH has the poorest outcome followed by concentric hypertrophy and concentric remodeling. TAVR patients with initially no hypertrophy had the best survival compared to the other groups.
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