impact of tavr on coronary hemodynamics and left ventricular performance · 2019-05-24 · impact...

Impact of TAVR on Coronary HemodynamicsImpact of TAVR on Coronary HemodynamicsImpact of TAVR on Coronary HemodynamicsImpact of TAVR on Coronary Hemodynamics

and Left Ventricular Performanceand Left Ventricular Performance

Interventional Cardiology 2017Interventional Cardiology 201732th Annual International Symposium32th Annual International Symposium32th Annual International Symposium32th Annual International Symposium

Karel T. KochKarel T. Koch MD, PhDMD, PhD

Esther WiegerinckEsther Wiegerinck MD PhDMD PhD,,

Tim P. Verhoef MD PhD, M C Rolandi MD, Martijn S. vanMourik MD,Tim P. Verhoef MD PhD, M C Rolandi MD, Martijn S. vanMourik MD,Tim P. Verhoef MD PhD, M C Rolandi MD, Martijn S. vanMourik MD,Tim P. Verhoef MD PhD, M C Rolandi MD, Martijn S. vanMourik MD,

Ze Y. Yong, MD PhD, Floor vanKesteren MD, Maurice Remmelink MD PhDZe Y. Yong, MD PhD, Floor vanKesteren MD, Maurice Remmelink MD PhD

Jan J. Piek MD PhD, Jan Baan Jr MD PhD.Jan J. Piek MD PhD, Jan Baan Jr MD PhD.

Academic Medical Center AmsterdamK.T.KOCH SNOWMASS 2017

Interventional Cardiology

Academic Medical Center,Academic Medical Center,

University of Amsterdam, Amsterdam, The NetherlandsUniversity of Amsterdam, Amsterdam, The Netherlands

No disclosuresNo disclosures



BackgroundBackground

Aortic valve stenosis (AS) induces compensatory increase in leftAortic valve stenosis (AS) induces compensatory increase in leftventricular mass to counteract the resistance to cardiac outflowventricular mass to counteract the resistance to cardiac outflow





This leads to alterations in coronary and left ventricular hemodynamics,This leads to alterations in coronary and left ventricular hemodynamics,associated with microvascular dysfunctionassociated with microvascular dysfunctionassociated with microvascular dysfunctionassociated with microvascular dysfunction






Contributors are: increased LVContributors are: increased LV--load, reduced diastolic perfusion time, andload, reduced diastolic perfusion time, andContributors are: increased LVContributors are: increased LV--load, reduced diastolic perfusion time, andload, reduced diastolic perfusion time, andthe absolute magnitude of the aortic valve area.the absolute magnitude of the aortic valve area.






Contributors are: increased LVContributors are: increased LV--load, reduced diastolic perfusion time, andload, reduced diastolic perfusion time, andContributors are: increased LVContributors are: increased LV--load, reduced diastolic perfusion time, andload, reduced diastolic perfusion time, andthe absolute magnitude of the aortic valve area.the absolute magnitude of the aortic valve area.

Relief of AS by transcatheter aortic valve replacement (TAVR) decreasesRelief of AS by transcatheter aortic valve replacement (TAVR) decreasesRelief of AS by transcatheter aortic valve replacement (TAVR) decreasesRelief of AS by transcatheter aortic valve replacement (TAVR) decreasesleft ventricular afterload and is expected to improve LV dynamics andleft ventricular afterload and is expected to improve LV dynamics andmicrovascular function immediatelymicrovascular function immediately



ObjectivesObjectives

To provide insight in the effects of AS and TAVR on:To provide insight in the effects of AS and TAVR on:To provide insight in the effects of AS and TAVR on:To provide insight in the effects of AS and TAVR on:

-- Left ventricular hemodynamics by direct invasiveLeft ventricular hemodynamics by direct invasive-- Left ventricular hemodynamics by direct invasiveLeft ventricular hemodynamics by direct invasiveassessmentassessment

-- Coronary hemodynamics by assessment of the coronaryCoronary hemodynamics by assessment of the coronarycirculation using simultaneous invasive coronary pressurecirculation using simultaneous invasive coronary pressureand flow velocity measurementsand flow velocity measurementsand flow velocity measurementsand flow velocity measurements



The effects of TAVR on left ventricular dynamics:The effects of TAVR on left ventricular dynamics:

MethodsMethods

Invasive intraventricular pressure and volume (PV) were simultaneouslyInvasive intraventricular pressure and volume (PV) were simultaneouslyassessed in 10 patients directly before and after TAVR by a pressureassessed in 10 patients directly before and after TAVR by a pressure--conductance catheter positioned in the LVconductance catheter positioned in the LV (CD Leycom, Netherlands)(CD Leycom, Netherlands)..conductance catheter positioned in the LVconductance catheter positioned in the LV ..

A SGA SG--catheter was placed in the AP for calibration purposes:catheter was placed in the AP for calibration purposes:Cardiac output was determined by thermodilution and parallelCardiac output was determined by thermodilution and parallelCardiac output was determined by thermodilution and parallelCardiac output was determined by thermodilution and parallelconduction was determined by hypertonic saline injections to calibrateconduction was determined by hypertonic saline injections to calibratethe volume signals of the conduction catheter.the volume signals of the conduction catheter.

PressurePressure--volume loop (PVvolume loop (PV--loop) assessment was performed andloop) assessment was performed andparameters for systolic and diastolic LV function as well as afterloadparameters for systolic and diastolic LV function as well as afterloadwere assessed.were assessed.were assessed.were assessed.

After TAVR, the conductance catheter and SG catheter were reinserted,After TAVR, the conductance catheter and SG catheter were reinserted,for calibration and repeated PVfor calibration and repeated PV--loop assessment for offloop assessment for off--line analysis.line analysis.



for calibration and repeated PVfor calibration and repeated PV--loop assessment for offloop assessment for off--line analysis.line analysis.

TAVR was performed under local anesthesiaTAVR was performed under local anesthesia


Patient characteristicsPatient characteristics (n=10)(n=10)

Patient characteristicsPatient characteristics

PrePre-- and post TAVR echocardiographic characteristicsand post TAVR echocardiographic characteristicsPrePre-- and post TAVR echocardiographic characteristicsand post TAVR echocardiographic characteristics



The effects of TAVR on left ventricular dynamicsThe effects of TAVR on left ventricular dynamics

Example of PressureExample of Pressure--Volume loopVolume loop

Schematic example of PVSchematic example of PV--loop preloop pre-- and post TAVR:and post TAVR:



Schematic example of PVSchematic example of PV--loop preloop pre-- and post TAVR:and post TAVR:Left and downward shift of the curve after TAVRLeft and downward shift of the curve after TAVR


Result (1)Result (1)

Effects of TAVR on global LVEffects of TAVR on global LV--functionfunction

Ejectionfraction increased (54% to 62%)Ejectionfraction increased (54% to 62%)Ejectionfraction increased (54% to 62%)Ejectionfraction increased (54% to 62%)Stroke volume increased (71 ml to 85 ml)Stroke volume increased (71 ml to 85 ml)Stroke work decreased (11222 to 9518)Stroke work decreased (11222 to 9518)




Results (2)Results (2)

Effects of TAVR on systolic functionEffects of TAVR on systolic function

Significant decrease of:Significant decrease of:LVLV--endsystolic pressureendsystolic pressure (171.3(171.3±±21to13821to138±±39mmHg: p=0.001)39mmHg: p=0.001)



LVLV--endsystolic pressureendsystolic pressure (171.3(171.3±±21to13821to138±±39mmHg: p=0.001)39mmHg: p=0.001)

LV endsystolic volumeLV endsystolic volume (71(71±±27to4927to49±±29ml; p=0.001)29ml; p=0.001)



Effects on afterload after TAVREffects on afterload after TAVR

As an index of afterload, the effective arterial elastance (EA) was usedAs an index of afterload, the effective arterial elastance (EA) was used



As an index of afterload, the effective arterial elastance (EA) was usedAs an index of afterload, the effective arterial elastance (EA) was used(calculated by endsystolic pressure/stroke volume)(calculated by endsystolic pressure/stroke volume)

EA decreased significantlyEA decreased significantly (2.61(2.61±±0.95 to1.750.95 to1.75±±0.77mmHg/ml; p=0.006)0.77mmHg/ml; p=0.006)



Afterload and contractility effects preAfterload and contractility effects pre-- and post TAVRand post TAVR




Alterations in cardiovascular interactionAlterations in cardiovascular interaction

ArterioArterio--ventricular couplingventricular coupling (effective arterial elastance/endsystolic elastance)(effective arterial elastance/endsystolic elastance)

ArterialArterial--ventricular coupling decreased towards normalventricular coupling decreased towards normal(1.13(1.13±±0.61 to 0.660.61 to 0.66±±0.49 p=.001)0.49 p=.001)



ArterialArterial--ventricular coupling decreased towards normalventricular coupling decreased towards normal(1.13(1.13±±0.61 to 0.660.61 to 0.66±±0.49 p=.001)0.49 p=.001)

indicating that cardiovascular energy efficiency improved after TAVR.indicating that cardiovascular energy efficiency improved after TAVR.


Alterations in cardiovascular interactionAlterations in cardiovascular interaction

Cardiovascular interaction preCardiovascular interaction pre-- and post TAVRand post TAVR

The endThe end--systolic elastance increased significantly, as did thesystolic elastance increased significantly, as did theventricular arterial coupling ratio, indicating an improvedventricular arterial coupling ratio, indicating an improvedinteraction of LV performance of the cardiovascular systeminteraction of LV performance of the cardiovascular systeminteraction of LV performance of the cardiovascular systeminteraction of LV performance of the cardiovascular system

The interaction was not improved during diastole, indicated by anThe interaction was not improved during diastole, indicated by anunaltered endunaltered end--diastolic stiffness.diastolic stiffness.



unaltered endunaltered end--diastolic stiffness.diastolic stiffness.


SummarySummary

TAVR immediately reduces afterload and markedly improves LV systolicTAVR immediately reduces afterload and markedly improves LV systolicperformance and interaction with the vascular system by invasive PVperformance and interaction with the vascular system by invasive PV--loop measurementsloop measurementsloop measurementsloop measurements




SummarySummary


TAVR immediately induces a leftward and concomittant downward shiftTAVR immediately induces a leftward and concomittant downward shiftin the LV systolic pressure volume relationshipin the LV systolic pressure volume relationshipin the LV systolic pressure volume relationshipin the LV systolic pressure volume relationship

Diastolic function remained unaltered immediately after TAVRDiastolic function remained unaltered immediately after TAVR




SummarySummary




Direct PVDirect PV--loop assessment revealed the first step towards LVloop assessment revealed the first step towards LV--remodeling after TAVRremodeling after TAVR




SummarySummary




Direct PVDirect PV--loop assessment revealed the first step towards LVloop assessment revealed the first step towards LV--remodeling after TAVRremodeling after TAVR

Limitations: results may be specific for patients with severe AS.Limitations: results may be specific for patients with severe AS.

Limited number of patients due to complexity of the measurementsLimited number of patients due to complexity of the measurements



Limited number of patients due to complexity of the measurementsLimited number of patients due to complexity of the measurements

Coronary hemodynamics:Coronary hemodynamics:methodsmethods

A total of 55 patients:A total of 55 patients:-- 27 patients with AS undergoing transfemoral TAVR27 patients with AS undergoing transfemoral TAVR-- 28 patients as a controls, no AS, elective physiological assessment of28 patients as a controls, no AS, elective physiological assessment of-- 28 patients as a controls, no AS, elective physiological assessment of28 patients as a controls, no AS, elective physiological assessment ofan angiografically unobstructed coronary artery.an angiografically unobstructed coronary artery.

Dual sensorDual sensor--equipped guidewire to assess intracoronary pressure andequipped guidewire to assess intracoronary pressure andflow velocityflow velocity (Combo(Combo--wire, Volcano Corp. San Diego)wire, Volcano Corp. San Diego)

Intracoronary measurements were performed during resting conditionsIntracoronary measurements were performed during resting conditionsand hyperemia (adenosine)and hyperemia (adenosine)and hyperemia (adenosine)and hyperemia (adenosine)

In TAVR patients: intracoronary measurements immediately before andIn TAVR patients: intracoronary measurements immediately before andimmediately after valve placementimmediately after valve placementimmediately after valve placementimmediately after valve placement

TAVR under local anesthesia: Edwards Sapien XT and 3, Corevalve.TAVR under local anesthesia: Edwards Sapien XT and 3, Corevalve.



TTE assessment was performed prior to and after TAVRTTE assessment was performed prior to and after TAVR

Coronary hemodynamics:Coronary hemodynamics:data analysisdata analysis

FFR:FFR:ratio between mean distal coronary and aortic pressure duringratio between mean distal coronary and aortic pressure duringratio between mean distal coronary and aortic pressure duringratio between mean distal coronary and aortic pressure duringmaximum hyperemiamaximum hyperemia

CFR:CFR:CFR:CFR:ratio between coronary flow velocity at maximum hyperemia and flowratio between coronary flow velocity at maximum hyperemia and flowvelocity at restvelocity at rest

Microvascular resistance index:Microvascular resistance index:Defined as the ratio of mean distal coronary pressure to average peakDefined as the ratio of mean distal coronary pressure to average peakflow velocityflow velocityflow velocityflow velocityAt baseline (BMR) and at hyperemia (HMR)At baseline (BMR) and at hyperemia (HMR)



Patient characteristicsPatient characteristics



Echocardiography preEchocardiography pre-- and postproceduraland postprocedural

Significant AR present in 6/27 patients 22%Significant AR present in 6/27 patients 22%



Coronary flow velocityCoronary flow velocity

Baseline flow velocityBaseline flow velocity Hyperemic flow velocityHyperemic flow velocity

Baseline flow velocity pre TAVRBaseline flow velocity pre TAVRBaseline flow velocity pre TAVRBaseline flow velocity pre TAVRwas higher than controls and did not change significantly after TAVRwas higher than controls and did not change significantly after TAVR

Hyperemic flow velocityHyperemic flow velocity



Hyperemic flow velocityHyperemic flow velocityincreased after TAVR and reached values equivalent to controlsincreased after TAVR and reached values equivalent to controls

Coronary flow reserve (CFR)Coronary flow reserve (CFR)

-- AS patients had a significantly lower CFR than controls (p<0.001)AS patients had a significantly lower CFR than controls (p<0.001)-- TAVR yielded a significant increase in CFR (p=0.009)TAVR yielded a significant increase in CFR (p=0.009)-- CFR increased towards reference values after TAVR,CFR increased towards reference values after TAVR,



-- CFR increased towards reference values after TAVR,CFR increased towards reference values after TAVR,but remained lower than controlsbut remained lower than controls

Microvascular resistanceMicrovascular resistance

Baseline microvascularBaseline microvascularresistance indexresistance index

Hyperemic microvascularHyperemic microvascularresistance indexresistance index

Baseline microvascular resistance preBaseline microvascular resistance pre--TAVR was significantly lower (p=0.02)TAVR was significantly lower (p=0.02)than controls, and did not increase significantly after TAVR (p=0.41)than controls, and did not increase significantly after TAVR (p=0.41)

Hyperemic microvascular resistance decreased significantly(p=0.05) post TAVRHyperemic microvascular resistance decreased significantly(p=0.05) post TAVR



Hyperemic microvascular resistance decreased significantly(p=0.05) post TAVRHyperemic microvascular resistance decreased significantly(p=0.05) post TAVR

ResultsResults

Fractional Flow Reserve (FFR)Fractional Flow Reserve (FFR)

FFRFFR (mean distal coronary to mean aortic pressure ratio during hyperemia)(mean distal coronary to mean aortic pressure ratio during hyperemia)

decreased from 0.97decreased from 0.97±±0.05 prior to TAVR to 0.950.05 prior to TAVR to 0.95±±0.06 post TAVR (p=0.042)0.06 post TAVR (p=0.042)

FFR is determined by the magnitude of transstenotic flow during hyperemia,FFR is determined by the magnitude of transstenotic flow during hyperemia,

which in turn depends on hyperemic microvascular resistancewhich in turn depends on hyperemic microvascular resistance

We demonstrated that TAVR decreases microvascular resistance and therebyWe demonstrated that TAVR decreases microvascular resistance and thereby

increases hyperemic flow.increases hyperemic flow.

Thus, TAVR is likely to influence stenosis assessment using FFRThus, TAVR is likely to influence stenosis assessment using FFR

FFR decreased significantly after TAVR, even in angiographically normal arteriesFFR decreased significantly after TAVR, even in angiographically normal arteries

Therefore, these results suggest that FFR assessment may underestimateTherefore, these results suggest that FFR assessment may underestimate

functional stenosis severity in AS patientsfunctional stenosis severity in AS patients



Coronary hemodynamics in AS and TAVR summarized:Coronary hemodynamics in AS and TAVR summarized:

In aortic valve stenosis, microvascular dysfunction originates from aIn aortic valve stenosis, microvascular dysfunction originates from acombination of physiological compensatory vasodilatation of thecombination of physiological compensatory vasodilatation of theautoregulated microvasculature and a pathological increase inautoregulated microvasculature and a pathological increase inautoregulated microvasculature and a pathological increase inautoregulated microvasculature and a pathological increase inmicrovascular resistance.microvascular resistance.





This results in a reduction of the vasodilatory reserve capacity of theThis results in a reduction of the vasodilatory reserve capacity of theThis results in a reduction of the vasodilatory reserve capacity of theThis results in a reduction of the vasodilatory reserve capacity of thecoronary microcirculation and CFR.coronary microcirculation and CFR.






TAVR induces an immediate decrease in hyperemic microvascularTAVR induces an immediate decrease in hyperemic microvascularresistance and an immediate increase in hyperemic flow velocity whileresistance and an immediate increase in hyperemic flow velocity whileresting hemodynamics remain unalteredresting hemodynamics remain unaltered




In aortic valve stenosis microvascular dysfunction originates from aIn aortic valve stenosis microvascular dysfunction originates from acombination of physiological compensatory vasodilatation of thecombination of physiological compensatory vasodilatation of theautoregulated microvasculature and a pathological increase inautoregulated microvasculature and a pathological increase inautoregulated microvasculature and a pathological increase inautoregulated microvasculature and a pathological increase inmicrovascular resistance.microvascular resistance.


TAVR induces an immediate decrease in hyperemic microvascularTAVR induces an immediate decrease in hyperemic microvascularresistance and an immediate increase in hyperemic flow velocity whileresistance and an immediate increase in hyperemic flow velocity whileresting hemodynamics remain unalteredresting hemodynamics remain unaltered

TAVR is thereby associated with an immediate improvement in theTAVR is thereby associated with an immediate improvement in thereserve vasodilatory capacity of the coronary microcirculation and CFR,reserve vasodilatory capacity of the coronary microcirculation and CFR,



reserve vasodilatory capacity of the coronary microcirculation and CFR,reserve vasodilatory capacity of the coronary microcirculation and CFR,in particular in patients without AR after TAVRin particular in patients without AR after TAVR

In conclusion:In conclusion:

TAVR immediately reduces LVTAVR immediately reduces LV--afterload and improves LV systolicafterload and improves LV systolicperformance as assessed by intraventricular PVperformance as assessed by intraventricular PV--loop measurements.loop measurements.Diastolic function remains unaltered immediately after TAVR.Diastolic function remains unaltered immediately after TAVR.

The vasodilatory reserve capacity of the coronary circulation is reducedThe vasodilatory reserve capacity of the coronary circulation is reducedin AS. TAVR induces an immediate decrease in hyperemic microvascularin AS. TAVR induces an immediate decrease in hyperemic microvascularin AS. TAVR induces an immediate decrease in hyperemic microvascularin AS. TAVR induces an immediate decrease in hyperemic microvascularresistance and concomittant increase in hyperemic flow velocity,resistance and concomittant increase in hyperemic flow velocity,resulting in immediate improvement in coronary vasodilatory reserve.resulting in immediate improvement in coronary vasodilatory reserve.





Thank you for your kind attentionThank you for your kind attention


Background and objectivesBackground and objectives

In patients with aortic stenosis (AS) the afterload and theIn patients with aortic stenosis (AS) the afterload and theIn patients with aortic stenosis (AS) the afterload and theIn patients with aortic stenosis (AS) the afterload and theenddiastolic volume increasesenddiastolic volume increases

These alterations are associated with a compensatory increaseThese alterations are associated with a compensatory increasein endin end--diastolic volume and pressure, and may eventuallydiastolic volume and pressure, and may eventuallyinduce LVinduce LV--dysfunctiondysfunction

Treatment of AS by transcatheter valve replacement (TAVR)Treatment of AS by transcatheter valve replacement (TAVR)decreases ventricular afterload and is expected to improve LVdecreases ventricular afterload and is expected to improve LVdecreases ventricular afterload and is expected to improve LVdecreases ventricular afterload and is expected to improve LVhemodynamicshemodynamics



Coronary hemodynamics:Coronary hemodynamics:data analysisdata analysis

FFR: ratio between mean distal coronary and aortic pressure duringFFR: ratio between mean distal coronary and aortic pressure duringmaximum hyperemiamaximum hyperemia

CFR: ratio between coronary flow velocity at maximum hyperemia andCFR: ratio between coronary flow velocity at maximum hyperemia andflow velocity at restflow velocity at rest

Microvascular resistance index:Microvascular resistance index:Defined as the ratio of mean distal coronary pressure to average peakDefined as the ratio of mean distal coronary pressure to average peakflow velocityflow velocityflow velocityflow velocityAt baseline (BMR) and at hyperemia (HMR)At baseline (BMR) and at hyperemia (HMR)

The ability of the resistance vessels to dilate under maximal hyperemicThe ability of the resistance vessels to dilate under maximal hyperemicThe ability of the resistance vessels to dilate under maximal hyperemicThe ability of the resistance vessels to dilate under maximal hyperemicconditions (variable arteriolar resistanceconditions (variable arteriolar resistance –– VAR) was defined as theVAR) was defined as thedifference between baseline (BMR) and hyperemic microvasculardifference between baseline (BMR) and hyperemic microvascularresistance (HMR), and was expressed both in absolute terms, as in aresistance (HMR), and was expressed both in absolute terms, as in apercentage of baselinepercentage of baseline



percentage of baselinepercentage of baseline

Results (1):Results (1):

Aortic valve stenosis vs reference vesselAortic valve stenosis vs reference vessel



Results: preTAVR vs post TAVR (n=27)Results: preTAVR vs post TAVR (n=27)



Results: preTAVR vs post TAVR (without AR n=20)Results: preTAVR vs post TAVR (without AR n=20)



Results: post TAVR vs reference vesselResults: post TAVR vs reference vessel



impact of tavr on coronary hemodynamics and left ventricular performance · 2019-05-24 · impact...

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