Early changes in diastolic function after TAVI: a guideline-based analysis of diastolic improvement patterns

Background Relief of left ventricular afterload after transcatheter aortic valve implantation (TAVI) may induce rapid changes in diastolic function. However, the extent of these changes, and which diastolic parameters are the main drivers of these changes after TAVI remain unclear. The 2024 British Society of Echocardiography (BSE) algorithm1 evaluates diastolic function hierarchically: first-line BSE triad (E/e′, TR velocity, LAVi) combines surrogates of filling pressure and pulmonary pressure with a marker of LA remodeling, followed by an intermediate adjudication stage (LA strain, e' velocities) and supplementary parameters. Purpose To assess early changes in diastolic function after TAVI, according to the sequential BSE 2024 algorithm, and the diastolic parameters that primarily drive these changes. Methods We retrospectively analyzed patients who underwent transfemoral TAVI, who had full echocardiographical acquisitions before and early after TAVI. Diastolic function was graded according to the BSE 2024 algorithm. Improvement of diastolic function was defined as transition to a lower diastolic dysfunction grade. Parameter normalization was defined as abnormal pre-TAVI values becoming normal post-TAVI, according to guideline cut-off values. Results Eighty-eight patients were included (mean age 77±5 years; 57% women; 85% in sinus rhythm; median NT-proBNP 730 pg/mL). After a median of 2.5 days post-TAVI, diastolic function improved in 45% of patients. Most transitions occurred from impaired diastolic function with elevated filling pressures to impaired function with normal filling pressures (Figure 1). Among improved patients, E/e′ decreased from 17.3±7.6 to 11.1±3.1 (p<0.001) and TR velocity from 2.32±0.69 to 2.07±0.52m/s (p=0.031), while changes in myocardial functional and structural parameters did not reach statistical significance (LAVI: 51.3±12.8 vs 48.6±14.9 mL/m²; LVEF: 61.5±9.5 vs 58.7±8.5%; GLS: −21.6±5.8 vs −20.3±5.8%); first-line BSE triad shifted importantly towards normal values: TR velocity normalized 100% patients, elevated E/e′ normalized in 88.9%, while LAVi normalized in 30.3%, compared with lower normalization rates of 71.4%, 10%, and 15.8%, respectively, in patients without diastolic improvement. Downstream parameters shifted similarly, irrespective of diastolic improvement for LA reservoir strain (70% vs 59%), but differently for e' velocities (82 vs 44%; p=0.02) (Figure 2). Overall, normalization of E/e′ showed the strongest association with diastolic grade improvement (OR 32.0; p<0.001), followed by TR velocity (OR 2.73; p=0.047). Conclusions Early diastolic improvement after TAVI is common, and is predominantly driven by rapid normalization of markers of filling pressure and pulmonary pressure (first-line BSE 2024 diagnostic pathway), while myocardial and structural parameters demonstrate limited short-term change.Figure 1Figure 2