Author + information
- Received May 16, 2019
- Revision received July 3, 2019
- Accepted July 16, 2019
- Published online November 4, 2019.
- Mackram F. Eleid, MDa,∗ (, )
- Ratnasari Padang, MBBS, PhDa,
- Sorin V. Pislaru, MD, PhDa,
- Kevin L. Greason, MDb,
- Juan Crestanello, MDb,
- Vuyisile T. Nkomo, MD, MPHa,
- Patricia A. Pellikka, MDa,
- Jacob C. Jentzer, MDa,
- Rajiv Gulati, MD, PhDa,
- Gurpreet S. Sandhu, MD, PhDa,
- David R. Holmes Jr., MDa,
- Rick A. Nishimura, MDa,
- Charanjit S. Rihal, MD, MBAa and
- Barry A. Borlaug, MDa
- aDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- bDepartment of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Mackram F. Eleid, Department of Cardiovascular Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905.
Objectives The aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV–pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS).
Background RV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading.
Methods Prospective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR.
Results Forty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m2). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm5) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm2; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m2; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm5; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001).
Conclusions Acute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.
- aortic stenosis
- pulmonary vascular function
- right ventricular function
- transcatheter aortic valve replacement
This work was funded by the Department of Cardiovascular Medicine, Mayo Clinic. Dr. Rihal has served as a consultant and done research with Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 16, 2019.
- Revision received July 3, 2019.
- Accepted July 16, 2019.
- 2019 American College of Cardiology Foundation
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