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Diastolic Dysfunction and Health Status After TAVR
Study Questions:
What is the association between baseline left ventricular diastolic dysfunction (LVDD) and disease-specific health status in patients with severe aortic stenosis before and after undergoing transcatheter aortic valve replacement (TAVR)?
Methods:
All patients who underwent commercial TAVR between 2012 and 2017 at Saint Luke’s Mid America Heart Institute were screened. Those with mitral stenosis, greater than moderate mitral regurgitation, history of mitral valve replacement, severe mitral annular calcification, atrial fibrillation, or paced rhythm were excluded, as these issues precluded accurate LVDD assessment. Patients’ LVDD grade (0-3) was then classified according to the American Society of Echocardiography guidelines on both baseline and post-TAVR follow-up echocardiography. Health status was evaluated at baseline and at 1- and 12-month follow-up by using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ). The KCCQ has been validated in both heart failure and aortic stenosis and contains five key domains which produce an overall summary score (KCCQ-OS), with higher score reflecting better health status. A linear trend test was used to associate LVDD with health status at baseline and follow-up. Association with the change in KCCQ-OS (health status recovery) was assessed via a linear mixed model, which allowed for adjustment for baseline KCCQ-OS.
Results:
Of the 587 patients screened, LVDD could be assessed in 304 patients. Of this analytical cohort, mean age was 81 ± 8.5 years and 41% were women. LVDD grades of 0, 1, 2, and 3 were assigned to 24 (8%), 54 (18%), 186 (61%), and 40 (13%), respectively. Higher grade LVDD was more likely to be seen in older patients with prior myocardial infarction or coronary artery bypass grafting and was associated with lower ejection fraction and larger left atrial volume index (p < 0.001). Aortic valve areas and transvalvular gradients, however, were similar across all LVDD grades. Baseline KCCQ-OS score was 47 ± 25 for the whole cohort and 61 ± 24, 51 ± 26, 45 ± 26, and 44 ± 22 for LVDD grades 0, 1, 2, and 3, respectively (p = 0.004). At 1- and 12-month follow-up, KCCQ-OS scores for the whole cohort improved significantly (68 ± 23 and 68 ± 4, respectively) and similarly across all grades of LVDD. In fact, higher grades of LVDD were no longer associated with worsened health status, and patients with higher LVDD actually had a significantly higher chance of having a change ≥20 in KCCQ-OS score (p = 0.03). Of the 215 (71%) and 142 (47%) patients with interpretable echocardiograms at 1- and 12-month follow-up, 26% and 30% had improvement in LVDD, but there was no association between improved LVDD grade and change in KCCQ-OS (p = 0.89).
Conclusions:
A higher degree of LVDD was associated with poorer health status at baseline, but the health status benefits from TAVR were robust across all grades of LVDD. LVDD improved in 25-30% of patients after TAVR, but these improvements were not associated with changes in health status.
Perspective:
There were several limitations to this study, most notably the modest sample size (underpowered to detect differences between subgroups), and the significant chance of selection bias in several areas: 1) Initial cohort only included patients in whom LVDD could be assessed on echocardiography (excluding 48%); and 2) follow-up LVDD was only assessed in 71% and 42% of patients. However, the conclusions strongly suggest that LVDD should not be considered a contraindication to TAVR. In fact, at least in this study, LVDD improved in a substantial number of patients after TAVR and patients with higher grades of initial LVDD were more likely to have bigger improvements in health status.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Cardiomyopathies, Coronary Artery Bypass, Echocardiography, Geriatrics, Health Status, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Myocardial Infarction, Stroke Volume, Transcatheter Aortic Valve Replacement, Ventricular Dysfunction, Left
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