title: Recovery of left ventricular mechanics after transcatheter aortic valve implantation: effects of baseline ventricular function and postprocedural aortic regurgitation.
abstract: BACKGROUND
  Impaired left ventricular (LV) myocardial deformation is associated with adverse outcome in patients with severe aortic stenosis (AS). The aim of this retrospective study was to assess the impact of transcatheter aortic valve implantation (TAVI) on the recovery of myocardial mechanics and the influence of postprocedural aortic regurgitation (AR).
  
  
  METHODS
  Speckle-tracking echocardiography was used to assess multidirectional myocardial deformation (longitudinal and circumferential strain) and rotational mechanics (apical rotation and twist) before and at midterm follow-up after TAVI. Predictors of myocardial recovery, defined as a ≥20% relative increase in the magnitude of global longitudinal strain compared with baseline, were examined.
  
  
  RESULTS
  Sixty-four patients (median age, 83 years; interquartile range, 77-86 years) with severe AS and high surgical risk (mean European System for Cardiac Operative Risk Evaluation score, 20 ± 13%) were evaluated. Overall, LV longitudinal deformation was impaired at baseline compared with controls. At 5 ± 3 months after TAVI, LV longitudinal deformation had significantly improved only in the group of patients with baseline LV ejection fractions (LVEF) ≤ 55%: global longitudinal strain from -9.7 ± 3.7% to -11.8 ± 3.2% (P = .05), longitudinal strain rate from -0.44 ± 0.14 sec(-1) to -0.57 ± 0.16 sec(-1) (P = .001), and early diastolic strain rate from 0.38 ± 0.17 sec(-1) to 0.49 ± 0.18 sec(-1) (P = .01). In patients with normal LVEFs, LV twist was supraphysiologic at baseline and normalized after TAVI (from 16.1 ± 6.9° to 11.9 ± 6.2°, P = .004). In patients with baseline LVEFs ≤ 55%, circumferential deformation was impaired before TAVI and improved after TAVI. Baseline LVEF (odds ratio, 0.56 per 10% increment; P = .02) and global longitudinal strain (odds ratio, 0.65 per absolute 1% increment; P < .001) were significant predictors of myocardial recovery. LV mass, volumes, and longitudinal strain failed to favorably remodel in patients with post-TAVI important AR (defined as new mild post-TAVI AR or moderate or severe post-TAVI AR [either preexisting or new AR]).
  
  
  CONCLUSIONS
  TAVI restores LV function toward more physiologic myocardial mechanics in both normal- and depressed-LVEF groups. Patients with lower systolic function derive the most benefit in terms of longitudinal reverse remodeling. Postprocedural AR adversely affects LV structural and functional remodeling.
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada. Electronic address: frederic.poulin@uhn.ca.
authors.forename: Frédéric
authors.initials: F
authors.lastname: Poulin
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Shemy
authors.initials: S
authors.lastname: Carasso
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Horlick
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Harry
authors.initials: H
authors.lastname: Rakowski
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ki-Dong
authors.initials: KD
authors.lastname: Lim
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Heather
authors.initials: H
authors.lastname: Finn
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Feindel
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Matthias
authors.initials: M
authors.lastname: Greutmann
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Osten
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Cusimano
authors.affiliation: Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Anna
authors.initials: A
authors.lastname: Woo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging* / Q000209:etiology*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D004452:Echocardiography / Q000379:methods; D054459:Elasticity Imaging Techniques / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects*; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000209:etiology / Q000517:prevention & control*
keywords: Aortic stenosis; Myocardial mechanics; Paravalvular aortic regurgitation; Speckle-tracking echocardiography; Strain; Transcatheter aortic valve implantation