Early reverse remodeling and long-term mortality predictors after transcatheter aortic valve implantation in severe symptomatic aortic stenosis

Background In patients with aortic stenosis (AS), left ventricular (LV) remodeling is a complex process involving both structural and functional abnormalities due to increased pressure afterload. Evidence remains limited not only regarding early LV reverse remodeling post-TAVI, but also its potential prognostic significance. Purpose To assess: (1) early effect of TAVI on LV ejection fraction (LVEF), LV mass, and diastolic function; (2) relationship between age, sex, NYHA class, comorbidities (diabetes mellitus - DM, hypertension - HTN, coronary artery disease - CAD, chronic kidney disease - CKD), and changes in LVEF, LV mass, and diastolic function; (3) association between early echocardiographic changes and all-cause mortality, during long-term follow-up. Methods Transthoracic echocardiography was performed prior to TAVI and before hospital discharge (5 ± 4 days), in patients with severe symptomatic AS who underwent successful TAVI. LVEF was assessed by Simpson's method, LV mass by Devereux method, and diastolic function by E/A ratio and left atrial (LA) diameter. Patients were followed up to 7 years (mean 4.1±1.9 years) post-procedure for all-cause mortality. Results 147 patients (77.5±5.1 years, 51.1% women) were analyzed. At admission 73 patients (49.7%) were classified in NYHA class III and IV. LVEF improved from 52.5±11.5 to 54.9±10.7% (p<0.001) (Fig. 1). Interventricular septal wall (ISW) thickness regressed from 14.8±2.5 to 14.4±2.3 mm (p<0.001), posterior wall (PW) thicknesses from 13.1±2.0 to 12.6±2.0 mm (p<0.001), while LV mass decreased from 146.0±37.1 to 133.2±29.2 g/m2 (p<0.001) (Fig. 2). There were no significant changes in E/A ratio and LA diameter. Patients with insulin-dependent DM showed a greater regression in LV mass (t=2.5, p=0.012), while those with CKD showed a greater increase in LVEF (t=2.3, p=0.024). Patients classified as NYHA III and IV showed a better improvement in both LVEF (t=-3.7, p<0.001) and LV mass (t=2.5, p=0.011). Over the 7-year follow-up, 12 patients (8.2%) died. Inadequate regression of the ISW thickness was the strongest echocardiographic predictor of death (t=3.51, p=0.001); a lower, but still significant effect was observed for the PW thickness (t = 2.20, p = 0.034). CKD was associated with a three-fold increase in mortality (10.2% vs. 3.4%; χ²=4.96, p=0.026). Multivariable analysis identified CKD (OR=3.6, p=0.018) as the only independent predictor of late mortality (AUC=0.86). Conclusions There is an early significant LV reverse remodeling in patients who underwent successful TAVI, revealed by improvement of LV ejection fraction and regression of LV hypertrophy. Insulin-dependent DM, CKD, and NYHA III and IV were associated with greater LV reverse remodeling immediately after TAVI. The lack of LV hypertrophy regression and CKD were the strongest predictors of 7-year all-cause mortality, with CKD being independently associated with death.