Ventriculo–arterial coupling after TAVI: a mechanistic link between residual hemodynamic burden and persistent symptoms

Introduction Ventriculo–arterial coupling (VAC) reflects the interaction between left ventricular (LV) contractility and afterload and can be non-invasively estimated as the ratio of arterial elastance (Ea) to LV end-systolic elastance (Ees). In aortic stenosis (AS) elevated VAC at discharge after transcatheter aortic valve implantation (TAVI) has been linked to adverse midterm outcomes. Data regarding factors related to an increased VAC in patients with structural heart disease interventions are still scarce. Purpose To evaluate the correlates of post-procedural VAC and its relationship with functional status improvement after TAVI. Methods We enrolled 250 patients with severe AS who underwent TAVI between 2017 and 2024 (76.2±7.1 years, 54.8%men), evaluated right before and one month post-procedure. Comprehensive echocardiography included LV myocardial work (MW) parameters: Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), and Global Work Efficiency (GWE). Ea and Ees were calculated as ESP/SV and ESP/ESV, respectively (ESP-end-systolic pressure; SV-stroke volume; ESV-end-systolic volume). Results Indexed LV mass decreased after TAVI (147.9±38.4 vs 167.4±46.4 g/m², p<0.001), accompanied by improved systolic function, with higher LVEF (55.2±9.4 vs 51.4±11.8%, p<0.001) and better GLS (-14.3±3.7 vs -12.5±4.1%, p<0.001). MW parameters changed significantly after TAVI, with lower GWI (1622.1±464 vs 1828.8±686.1 mmHg%, p=0.003) and GWW (214.5±159.7 vs 251.2±122 mmHg, p=0.01), while GWE increased (89.7±5.8 vs 88.6±5.9%, p=0.06). Patients with patient–prosthesis mismatch had higher VAC compared with those without mismatch (0.81±0.61 vs 0.48±0.32, p<0.001). Similarly, patients with persistent NYHA III–IV symptoms exhibited higher post-TAVI VAC than those with functional improvement (0.76±0.66 vs 0.49±0.29, p=0.03).On univariate analysis, post-TAVI VAC correlated inversely with age, baseline LV functional and MW parameters (GWI,GCW,GWE,LVEF) and with post-procedural indexed aortic valve area and decrease of mean transvalvular gradient. Positive associations were found with baseline indexed LV mass, indexed LA volume and E/e′. In multivariable analysis, age (β −0.36, p<0.001), GWI (β −0.27, p 0.03), and decrease of mean transvalvular gradient (β −0.29, p 0.01) were independent correlates of post-procedural VAC. Conclusions Higher post-TAVI VAC values were associated with persistent NYHA class III–IV symptoms, suggesting that Ea/Ees index may identify patients with incomplete functional recovery. By contrast, lower VAC values were associated with better LV systolic performance, larger effective valve area and greater gradient reduction, suggesting that optimized valve hemodynamics translate into more favorable ventriculo–arterial interaction and improved energetic efficiency. These findings support the potential role of VAC as an integrated marker of both mechanical and clinical response after TAVI.