Characteristics And Prognosis Of Early Cardiac Reverse Remodeling After Transcatheter Aortic Valve Replacement

Background and purpose:Heart valve is the core of circulation.Due to the aging of the population,the prevalence of valvular heart disease is increasing worldwide,and the number of deaths caused by aortic stenosis(AS)has continued to rise in the past 20 years.AS not only leads to the obstruction of the cardiac outflow tract,but also induces a series of adverse cardiac structural and functional changes,which eventually leads to heart failure and death.There are no drugs that can effectively control or slow down the progression of AS,and aortic valve replacement remains the only available treatment for AS.Transcatheter aortic valve replacement(TAVR),as a minimally invasive valve replacement technology,has been developed for 20 years.It has become the standard treatment for patients with intermediate and high risk AS,and has begun to the low risk.TAVR can relieve valve obstruction in patients and induce cardiac morphology and function to return to normal.These changes are called reverse cardiac remodeling.At present,the reports on the initiation time of cardiac reverse remodeling after TAVR are not consistent,and whether left ventricular end-diastolic dimension(LVEDD)can be improved in the early stage after TAVR has not been reported.The aim of this study is to observe the onset time and characteristics of early cardiac reverse remodeling after TAVR,and further explore the related clinical factors affecting the prognosis of TAVR patients.Method:This was a single-center retrospective cohort study.A total of 113 patients with severe AS who underwent TAVR in the Second Affiliated Hospital of Army Medical University from December 2017 to December 2021 were enrolled.We collected the patients’ clinical data,cardiac ultrasound data,electrocardiogram data,blood biochemical test data,intraoperative conditions,postoperative follow-up conditions and complications.In this study,postoperative cardiac ultrasound was collected on the fourth day after TAVR on average,and the improvement of postoperative LVEDD ≥1.8 mm compared with preoperative LVEDD was defined as early LVEDD improvement.According to this criterion,patients were further divided into early LVEDD improvement group and early LVEDD non-improvement group.Patients were followed up at 1 month,6 months and 1 year after surgery through outpatient clinic or telephone.The endpoint was a composite of major adverse cardiovascular events(MACE),including all-cause death,myocardial infarction,and heart failure readmission at 1year after surgery.Outcome:1.The average age of the patients was(71.2±6.5)years old,including 59(52.2%)females.There was no significant difference in age and gender between the two groups(P>0.05).The proportion of peripheral atherosclerosis was higher in the early LVEDD non-improvement group(P<0.05),and the proportion of aortic regurgitation(AR)was higher in the early LVEDD improvement group(P<0.05).2.The preoperative and early postoperative LVEDD were(50.7±7.3)mm and(48.9±6.5)mm,respectively,and LVEDD was significantly shortened in the early postoperative period(P<0.001).Peak transvalvular velocity(Vmax),mean pressure gradient(MPG)and B-type natriuretic peptide(BNP)were significantly decreased compared with those before surgery(P<0.05).The left ventricular fractional shortening(LVFS)was significantly higher than that before operation(P<0.05),and the tricuspid regurgitation was also significantly improved in the early postoperative period(P<0.001).Left ventricular ejection fraction(LVEF)had a trend of increase compared with preoperative,but the difference was not statistically significant(P>0.05).The proportion of patients with left bundle branch block(LBBB)and third-degree atrioventricular block was significantly increased after operation(P<0.05),and the P-R interval and QRS interval of ECG were also significantly increased compared with those before operation,the difference was statistically significant(P<0.05).After operation,troponin I,serum creatinine and D-dimer were increased compared with those before operation,and the differences were statistically significant(P<0.05).3.Echocardiographic follow-up data analysis showed that LVFS in the early LVEDD improvement group increased significantly at 1 month after operation,and LVEF improved significantly at 6 months after operation(P<0.05).However,the postoperative LVFS and LVEF of the early LVEDD non-improvement group showed an improvement trend at different time points,but there was no statistical difference(P>0.05).MPG in early LVEDD improvement group was lower than that in early LVEDD non-improvement group at 1 year after TAVR,and the difference was statistically significant(P<0.05).4.The complication statistics showed that 7 patients(6.2%)died within 1 month after surgery,and 8 patients(7.1%)died within 1 year after surgery.The risk of death mainly occurred within 1 month after surgery.Permanent pacemaker(PPM)implantation was the main complication at 1 month(12.4%)and 1 year(13.3%).Correlation analysis showed that diabetes mellitus,postoperative BNP level,PPM implantation were positively correlated with the occurrence of MACE 1 year after TAVR(r>0,P<0.05),while early improvement of LVEDD was negatively correlated with the occurrence of MACE 1 year after TAVR(r=-0.30,P<0.05).5.Univariate Cox regression analysis showed that preoperative diabetes mellitus(HR: 2.635,95%CI 1.013-6.858,P=0.047)and postoperative PPM implantation(HR: 3.518,95%CI 1.336-9.263,P=0.011)were risk factors for MACE at 1 year after TAVR.Early improvement of LVEDD(HR: 0.176,95%CI 0.052-0.601,P=0.006)and preoperative Vmax(HR: 0.990,95%CI 0.983～0.997,P=0.006)were protective factors.Multivariate Cox analysis showed that postoperative BNP level(HR: 1.001,95%CI 1.000-1.001,P=0.008)was an independent risk factor for MACE at 1 year after surgery.Early improvement in LVEDD(HR: 0.231,95%CI 0.062-0.857,P=0.029)and preoperative Vmax(HR: 0.990,95%CI0.982-0.999,P=0.026)were independent protective factors for MACE at 1 year after TAVR.Conclusion:1.TAVR has a reliable effect in the treatment of severe AS,and can quickly improve the hemodynamic disorder of patients after surgery,and reverse cardiac remodeling can be observed as early as 4 days after surgery on average.Patients with early improvement of LVEDD have better continuous improvement of LVFS and LVEF than patients without early improvement of LVEDD.2.LBBB and third-degree atrioventricular block are common complications after TAVR.Postoperatively PPM implantation was negatively associated with early improvements in LVEDD,suggesting that PPM implantation may partially offset the early adverse cardiac remodeling benefits of TAVR therapy.3.Early improvement in LVEDD after TAVR is an independent protective factor for MACE at 1 year after TAVR,while postoperative BNP level is an independent risk factor for MACE at 1 year after TAVR.