Objectives

Aortic stenosis is one of the most common valvular diseases in the aging population. The invention of the transcatheter aortic valve replacement (TAVR) in 2002 was revolutionary for the treatment options especially in multimorbid high aged patients. Even if the TAVR results are promising in comparison to SAVR, some patients do not profit from TAVR.

Aortic stenosis causes a chronic pressure overload on the left ventricle leading to a reactive hypertrophic cardiac remodeling. The increasing left ventricular mass causes secondary myocardial damage such as degeneration and replacement of cardiomyocytes and myocardial fibrosis.

Different LV hypertrophy patterns in echocardiography were compared to identify a possible impact on periprocedural and 5-year outcome after TAVR and were evaluated in different subgroups.

Patients and methods

The study included 1483 patients with severe aortic stenosis who received TAVR between 01/2014 and 08/2022 in two major centers for TAVR in Munich and Kiel. According to LV mass index (LVMI) and relative wall thickness (RWT) patients were divided into 4 groups:

normal (n=57), concentric remodeling (RWT > 0.42; LVMI ≤ 95 g/m² for women and ≤ 115 g/m² for men) (CR; n=276), concentric hypertrophy (CH; n=981) and eccentric hypertrophy (EH; n=169). The data was analyzed retrospectively and correlated to the clinical outcome. Especially the comparison of the subgroups concentric hypertrophy and eccentric hypertrophy were of special interest.

Results

There was no significant difference in the occurrence of coronary heart disease (CHD) in the 4 groups.

The pre-interventional aortic valve area showed a statistically significant difference between the groups only in the separate analysis of the patient cohort in Munich.  Regarding the LV ejection fraction, logistic EuroSCORE I and previous myocardial infarction as well as aortic and mitral valve insufficiency, statistically significant differences were calculated especially with respect to the eccentric hypertrophy group.

Concerning the postprocedural outcome the mortality after one and five years was highest in the eccentric hypertrophy group.

Figure 1 shows the mid-term survival up to 5 years including a comparison of all 4 groups.


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 = <0.001).

Table 1 shows the dilatation of the LV based on the hypertrophy and the left ventricular ejection fraction.

Table 1. LV hypertrophy pattern divided by dilatation and left ventricular ejection fraction.

Conclusion

The majority of pre TAVR patients showed a concentric hypertrophy pattern. In comparison to the other groups, the EH group showed the poorest outcome after 1-year and mid-term follow up, followed by CH and CR. TAVR-patients with initially normal LV-pattern had the best outcome.

These results suggest that the high-risk group EH could benefit from a more precise monitoring during follow-up as well as from further studies to designate more predictors of poorer outcome.