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Dynamic changes in aortic impedance after transcatheter aortic valve replacement and its impact on exploratory outcome

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Abstract

Valvulo-arterial impedance (Zva) has been shown to predict worse outcome in medically managed aortic stenosis (AS) patients. We aimed to investigate the association between Zva and left ventricular (LV) adaptation and to explore the predictive value of Zva for cardiac functional recovery and outcome after transcatheter aortic valve replacement (TAVR). We prospectively enrolled 128 patients with AS who underwent TAVR. Zva was calculated as: (systolic blood pressure + mean transaortic gradient)/stroke volume index). Echocardiographic assessment occurred at baseline, 1-month and 1-year after TAVR. The primary endpoints were to investigate associations between Zva and global longitudinal strain (GLS) at baseline as well as GLS change after TAVR. The secondary was to compare all-cause mortality after TAVR between patients with pre-defined Zva (=5 mmHg m2/ml), stroke volume index (=35 ml/m2), and GLS (=−15%) cutoffs. The mean GLS was reduced (−13.0 ± 3.2%). The mean Zva was 5.2 ± 1.6 mmHg*m2/ml with 55% of values ≥5.0 mmHg*m2/ml, considered to be abnormally high. Higher Zva correlated with worse GLS (r = −0.33, p < 0.001). After TAVR, Zva decreased significantly (5.1 ± 1.6 vs. 4.5 ± 1.6 mmHg*m2/ml, p = 0.001). A reduction of Zva at 1-month was associated with GLS improvement at 1-month (r = −0.31, p = 0.001) and at 1-year (r = −0.36 and p = 0.001). By Kaplan–Meier analysis, patients with higher Zva at baseline had higher mortality (Log-rank p = 0.046), while stroke volume index and GLS did not differentiate outcome (Log-rank p = 0.09 and 0.25, respectively). As a conclusion, Zva is correlated with GLS in AS as well as GLS improvement after TAVR. Furthermore, a high baseline Zva may have an additional impact to traditional parameters on predicting worse mortality after TAVR.

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Abbreviations

AS:

Aortic stenosis

AVAI:

Aortic valve area index

EF:

Ejection fraction

GLS:

Global longitudinal strain

LA:

Left atrial

LV:

Left ventricular

TAVR:

Transcatheter aortic valve replacement

Zva:

Valvulo-arterial impedance

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Acknowledgements

We want to thank Stanford Cardiovascular Institute, and Pai Chan Lee Research Fund (FH) for their support.

Funding

NHLBI RO1 HL67025 (DCM), Stanford Cardiovascular Institute, Translational Research and Applied Medicine (JBK, FH, WFF) and Women’s Sex-Difference in Medicine Grant (YK, JBK, ROM, FH, WFF) from the Stanford Department of Medicine, and Pai Chan Lee Research Fund (FH).

Disclosure

DCM works as a Stanford PI (PARTNER Trials, Edwards Lifesciences; SURTAVI Trial, Medtronic) and has served as an Executive Committee for Edwards Lifesciences (PARTNER U.S. Pivotal Trial) and consultant for Medtronic.

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    Authors and Affiliations

    1. Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive Room H2103, Stanford, CA, 94305, USA

      Yukari Kobayashi, Juyong B. Kim, Kegan J. Moneghetti, Yuhei Kobayashi, Ran Zhang, Daniel A. Brenner, Ryan O’Malley, Ingela Schnittger, Michael Fischbein, D. Craig Miller, Alan C. Yeung, David Liang, Francois Haddad & William F. Fearon

    2. Stanford Cardiovascular Institute, Stanford, CA, USA

      Yukari Kobayashi, Juyong B. Kim, Kegan J. Moneghetti, Yuhei Kobayashi, Ran Zhang, Daniel A. Brenner, Ryan O’Malley, Ingela Schnittger, Michael Fischbein, D. Craig Miller, Alan C. Yeung, David Liang, Francois Haddad & William F. Fearon

    3. Kaiser Permanente, Hawaii Region, Moanalua Medical Center, Honolulu, HI, USA

      Daniel A. Brenner

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    1. Yukari Kobayashi
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    Francois Haddad and William F. Fearon have equally contributed to mentoring the project and are equivalent last authors.

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    Kobayashi, Y., Kim, J.B., Moneghetti, K.J. et al. Dynamic changes in aortic impedance after transcatheter aortic valve replacement and its impact on exploratory outcome. Int J Cardiovasc Imaging 33, 1693–1701 (2017). https://doi.org/10.1007/s10554-017-1155-6

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