School of Medicine and Health Sciences Poster Presentations

Title

Transcatheter Aortic Valve Replacement Improves Right Ventricular Hemodynamics in High Surgical Risk Patients with Aortic Stenosis

Document Type

Poster

Keywords

TAVR; Transcatheter Aortic Valve Replacement; aortic stenosis; high surgical risk; right ventricular function

Publication Date

Spring 2017

Abstract

Introduction

Aortic stenosis (AS) affects between 3-23% of elderly adults and is a major cause of morbidity and mortality. While surgical aortic valve replacement had been associated with prohibitive risk for many of these patients, transcatheter aortic valve replacement (TAVR) represents an emerging alternative approach. The hemodynamic efficacy of TAVR has been demonstrated in clinical trials; however, less is known in real- world practice. Specifically, AS worsens right ventricular function and pulmonary hypertension that may be associated with adverse outcomes. The goal of this study was to assess whether TAVR results in improvement of RV hemodynamics as measured by echocardiography.

Methods

We reviewed 62 patients referred for TAVR to an urban academic medical center from 2014-2016. Transthoracic echocardiography (TTE) was performed before and after TAVR according to American Society of Echocardiography guidelines. Pre-TAVR and post-TAVR TTE were reviewed at blinded separate sessions. RV function was assessed by tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler-derived tricuspid lateral annular systolic velocity (S’). RV size was quantified as the basal diameter in the apical four-chamber view. Pulmonary artery pressure was derived using tricuspid regurgitation velocity + right atrial pressure, with pulmonary artery hypertension defined as > 40 mm Hg. Left heart hemodynamics were also assessed using standard measures.

Results

The study included 29 patients with fully retrievable TTE imaging available for review. Mean age was 79 ± 9.2 years (range 63-94), 70% were men, and all were at high surgical risk (STS Score 7.1 ± 5.3, 33% hostile chest). Of the 29, 9 (31%) had mild to moderate chronic lung disease. RV size and FAC were similar pre and post TAVR. Significantly, TAVR resulted in improvement in pulmonary pressure in 14 patients (48% p=0.03), and RV function by TAPSE in 9 patients (p=0.03) and S’ in 9 patients (p=0.02). 27/29 (93%) of patients demonstrated no or trace aortic insufficiency after TAVR. Regarding the left heart, TAVR also significantly improved left ventricular ejection Fraction in 21 patients (72%; p=0.004), aortic valve peak velocity in all 29 patients (p<0.001) and aortic valve mean gradient in all 29 patients (p <0.001).

Conclusion

In this real-world cohort, TAVR resulted in improvement in pulmonary hypertension and RV function. As pulmonary hypertension has been associated with worse outcomes, our data suggests that further studies are needed to determine whether these improvements observed are predictive of better long-term outcomes.

**This abstract was also accepted as a poster presentation to the 2017 American College of Physician Internal Medicine Meeting.

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Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Open Access

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Comments

Poster to be presented at GW Annual Research Days 2017.

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Transcatheter Aortic Valve Replacement Improves Right Ventricular Hemodynamics in High Surgical Risk Patients with Aortic Stenosis

Introduction

Aortic stenosis (AS) affects between 3-23% of elderly adults and is a major cause of morbidity and mortality. While surgical aortic valve replacement had been associated with prohibitive risk for many of these patients, transcatheter aortic valve replacement (TAVR) represents an emerging alternative approach. The hemodynamic efficacy of TAVR has been demonstrated in clinical trials; however, less is known in real- world practice. Specifically, AS worsens right ventricular function and pulmonary hypertension that may be associated with adverse outcomes. The goal of this study was to assess whether TAVR results in improvement of RV hemodynamics as measured by echocardiography.

Methods

We reviewed 62 patients referred for TAVR to an urban academic medical center from 2014-2016. Transthoracic echocardiography (TTE) was performed before and after TAVR according to American Society of Echocardiography guidelines. Pre-TAVR and post-TAVR TTE were reviewed at blinded separate sessions. RV function was assessed by tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler-derived tricuspid lateral annular systolic velocity (S’). RV size was quantified as the basal diameter in the apical four-chamber view. Pulmonary artery pressure was derived using tricuspid regurgitation velocity + right atrial pressure, with pulmonary artery hypertension defined as > 40 mm Hg. Left heart hemodynamics were also assessed using standard measures.

Results

The study included 29 patients with fully retrievable TTE imaging available for review. Mean age was 79 ± 9.2 years (range 63-94), 70% were men, and all were at high surgical risk (STS Score 7.1 ± 5.3, 33% hostile chest). Of the 29, 9 (31%) had mild to moderate chronic lung disease. RV size and FAC were similar pre and post TAVR. Significantly, TAVR resulted in improvement in pulmonary pressure in 14 patients (48% p=0.03), and RV function by TAPSE in 9 patients (p=0.03) and S’ in 9 patients (p=0.02). 27/29 (93%) of patients demonstrated no or trace aortic insufficiency after TAVR. Regarding the left heart, TAVR also significantly improved left ventricular ejection Fraction in 21 patients (72%; p=0.004), aortic valve peak velocity in all 29 patients (p<0.001) and aortic valve mean gradient in all 29 patients (p <0.001).

Conclusion

In this real-world cohort, TAVR resulted in improvement in pulmonary hypertension and RV function. As pulmonary hypertension has been associated with worse outcomes, our data suggests that further studies are needed to determine whether these improvements observed are predictive of better long-term outcomes.

**This abstract was also accepted as a poster presentation to the 2017 American College of Physician Internal Medicine Meeting.