Left ventricular systolic recovery after TAVI in severe aortic stenosis: A systematic review and meta-analysis

Severe aortic stenosis (AS) imposes chronic pressure overload on the left ventricle (LV), leading to adverse remodeling and systolic dysfunction. While transcatheter aortic valve implantation (TAVI) can reverse this process, the overall prevalence and predictors of LV functional recovery are not fully understood. This study aims to assess the left ventricular ejection fraction (LVEF) recovery following TAVI. A meta-analysis was conducted in accordance with PRISMA guidelines. The PubMed, Scopus, Web of Science, and Cochrane databases were searched from inception through November 2024 for studies reporting on LVEF improvement after TAVI in patients with severe AS. The primary outcome was LVEF improvement, defined as an absolute increase of ≥10% from baseline. A random-effects model was employed for all pooled analyses to account for inter-study heterogeneity. Eighteen studies encompassing 4782 patients met the inclusion criteria. In the subgroup of patients with reduced LVEF, 14 studies with a total of 3182 patients reported a LV systolic recovery of 49% (95% CI: 40-57; I2 = 97%). The recovery was observed across all follow-up periods, from immediately post-procedure to one-year. A meta-regression has identified that baseline LVEF is a predictor of LV systolic recovery (β = -0.042 (95% CI: -0.075, -0.008, p=0.018, I2 = 93.31%). TAVI is associated with substantial LV systolic recovery in nearly half of all patients with pre-existing systolic dysfunction. These findings underscore the prognostic importance of myocardial recovery in this high-risk patient population and can inform clinical decision-making and patient counselling. Parts of the graphical abstract were drawn using pictures from Servier Medical Art ( smart.servier.com ), provided by Servier, licensed under a Creative Commons Attribution 4.0 license (CC BY 4.0). ( https://creativecommons.org/licenses/by/4.0/ ). • What is already known on this topic • It is recognized that Transcatheter Aortic Valve Implantation (TAVI) can lead to improved left ventricular function in patients with severe aortic stenosis. However, the overall rate of recovery and the factors predicting it were not well established, as previous studies were often small and provided varied results. • What this study adds • This meta-analysis, included 4782 patients from 18 studies (14 studies: only reduced baseline LVEF, and 4 studies; a mixture of reduced and preserved LVEF at baseline), where it established that significant left ventricular (LV) recovery improvement occurs in 43% of patients overall after TAVI. More importantly, it demonstrates that for the high-risk group with pre-existing left ventricular dysfunction, nearly half (49%) experience a substantial recovery of LV. The study confirms that a lower ejection fraction before the procedure is the single most powerful predictor of this positive outcome. • How this study might affect research, practice or policy • These findings provide a solid, evidence-based figure that clinicians can use to counsel patients, particularly those with reduced LVEF, about the potential benefits of TAVI, managing expectations by explaining there is roughly a 50% chance of significant LV recovery. The results also highlight the need for future research to focus on standardizing the definition of LV systolic recovery and using advanced imaging to better identify which patients are most likely to benefit.