Echocardiographic assessment of the right heart in patients with aortic stenosis undergoing transcatheter aortic valve implantation: analysis from a large single-center cohort
Authors: Brandao M , Mendes L , Diaz S , Santos-Ferreira D , Barros A , Rodrigues A , Braga P , Sampaio F , Fontes-Carvalho R 
Published: November 2023

Abstract

Introduction
The impact of right ventricular (RV) function and RV to pulmonary artery (RV-PA) coupling on outcomes of patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the early effect of the intervention in right heart echocardiographic parameters, remain partly unclear.

Aim
To evaluate the postprocedural trend of right heart echocardiographic (echo) parameters and its impact on the outcome of patients with aortic stenosis undergoing TAVI.

Methods
Retrospective analysis including consecutive patients submitted to TAVI at our center between 2007-2021.
Pre and postprocedural (≤96h) echo parameters were analyzed: tricuspid annular plane systolic excursion (TAPSE), S-wave tissue Doppler velocity of the tricuspid annulus (S'), pulmonary arterial systolic pressure (PASP). TAPSE/PASP ratio was used as a surrogate of RV-PA coupling; TAPSE/PASP ratio&lt;0.31 defined RV-PA uncoupling.
Primary endpoint (PE) was defined as all-cause death within 1-year after TAVI. Echo parameters were compared between patients according to the PE. Pairwise comparison of pre- and post-TAVI indexes was also performed, for the overall cohort and according to the PE. Statistical significance was considered if p&lt;0.05.

Results
Of 1051 TAVI patients, 615 with complete echo and follow-up data were included: median age 81(77-85) years, 53% female, median EuroSCORE II 3.6(2.1-5.7)%, median aortic valve mean gradient 47(39-56) mmHg, left ventricular ejection fraction 55(45-60)%. Before TAVI, 27 patients (11%) presented RV dysfunction (TAPSE&lt;17mm), and 30 (15%) with RV-PA uncoupling. At least moderate tricuspid regurgitation was present in 61 (10.6%) patients.
Overall, a significant reduction in PASP was observed after TAVI (40 vs 36 mmHg, p&lt;0.01). TAPSE decreased post-TAVI (20.0 vs 19.5 mm, p=0.04), while the TAPSE/PASP ratio increased (0.50 vs 0.57, p&lt;0.01) in the postprocedural period. S’ values did not differ between evaluations (11.20 vs 11.50, p=0.08). [image1]
The primary endpoint occurred in 54 (8.8%) of the 615 patients included. Patients who met the PE had higher preprocedural PASP (43 vs 39 mmHg, p=0.03), and more frequently presented RV-PA uncoupling at baseline (35% vs 24%, p=0.023).
PASP decreased after TAVI (39 vs 35 mmHg, p&lt;0.001) in patients who survived the first-year post-implantation, but not in patients meeting the PE (p=0.83) [image2]. Post-implantation PASP was significantly higher in patients who met the PE (40 vs 34, p=0.006). Postprocedural TAPSE/PASP ratio was lower in the deceased group (0.46 vs 0.58, p=0.014).

Conclusions
In this cohort, RV longitudinal function parameters did not improve after TAVI. Contrastingly, RV-PA coupling improved after the procedure post-TAVI, irrespectively of the PE. Patients who did not survive the 1st year after TAVI more frequently presented RV-PA uncoupling at baseline.