Aortic stenosis is one of the major valvular diseases in the ageing population. After the invention of the transcatheter aortic valve replacement (TAVR) in 2002, the treatment options for the aortic stenosis has been revolutionized. Despite the promising results in comparison to SAVR, there are still some 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 and were evaluated in different subgroups.
Patients and methods
The study included 273 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=54), concentric hypertrophy (CH; n=169) and eccentric hypertrophy (EH; n=34). The data was analysed retrospectively and correlated to the clinical outcome. Especially the subgroup eccentric hypertrophy was of special interest.
Results
No significant differences exist between the groups in relation to pre-interventional aortic valve area. Regarding the LV ejection fraction, the mean aortic gradient, NYHA III/IV classification and logistic EuroSCORE I a statistically significant difference was calculated especially to the eccentric hypertrophy group. There was no significant difference in the occurrence of coronary heart disease (CHD) in the 4 groups. Concerning the postprocedural outcome new onset of atrial fibrillation and cardiac mortality after 30 days was highest in the eccentric hypertrophy group.
Figure 1 shows the mid-term survival up to 4 years all 4 groups compared.
Figure 1. 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).
Table 1 shows the dilatation of the LV in each group divided by the presence of a CHD.
Table 1. LV hypertrophy pattern divided by dilatation and CHD.
Conclusion
Concentric hypertrophy is the most common hypertrophy pattern in pre-TAVR-patients. The group EH has the poorest outcome after 30 days, 1 year and mid-term follow-up followed by concentric hypertrophy and concentric remodeling. The best outcome was found in TAVR-Patients with initially no hypertrophy. Therefore the high risk group EH needs a more precise monitoring during follow-up as well as further studies to designate more risk factors which influence the outcome.
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