From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.).
Institute of Cardiovascular Science, University College London, United Kingdom (M.M., A.D.H., A.M.).
Hypertension. 2020 Jun;75(6):1557-1564. doi: 10.1161/HYPERTENSIONAHA.119.14385. Epub 2020 Apr 20.
Severe aortic stenosis induces abnormalities in central aortic pressure, with consequent impaired organ and tissue perfusion. Relief of aortic stenosis by transcatheter aortic valve replacement (TAVR) is associated with both a short- and long-term hypertensive response. Counterintuitively, patients who are long-term normotensive post-TAVR have a worsened prognosis compared with patients with hypertension, yet the underlying mechanisms are not understood. We investigated immediate changes in invasively measured left ventricular and central aortic pressure post-TAVR in patients with severe aortic stenosis using aortic reservoir pressure, wave intensity analysis, and indices of aortic function. Fifty-four patients (mean age 83.6±6.2 years, 50.0% female) undergoing TAVR were included. We performed reservoir pressure and wave intensity analysis on invasively acquired pressure waveforms from the ascending aorta and left ventricle immediately pre- and post-TAVR. Following TAVR, there were increases in systolic, diastolic, mean, and pulse aortic pressures (all <0.05). Post-TAVR reservoir pressure was unchanged (54.5±12.4 versus 56.6±14.0 mm Hg, =0.30) whereas excess pressure increased 47% (29.0±10.9 versus 42.6±15.5 mm Hg, <0.001). Wave intensity analysis (arbitrary units, au) demonstrated increased forward compression wave (64.9±35.5 versus 124.4±58.9, ×10 au, <0.001), backward compression wave (11.6±5.5 versus 14.4±6.9, ×10 au, =0.01) and forward expansion wave energies (43.2±27.3 versus 82.8±53.1, ×10 au, <0.001). Subendocardial viability ratio improved with aortic function effectively unchanged post-TAVR. Increased central aortic pressure following TAVR relates to increased transmitted power and energy to the proximal aorta with increased excess pressure but unchanged reservoir pressure. These changes provide a potential mechanism for the improved prognosis associated with relative hypertension post-TAVR.
严重的主动脉瓣狭窄会导致中心主动脉压异常，从而影响器官和组织灌注。经导管主动脉瓣置换术（TAVR）可缓解主动脉瓣狭窄，同时伴有短期和长期高血压反应。违反直觉的是，TAVR 后长期血压正常的患者预后比高血压患者更差，但潜在机制尚不清楚。我们使用主动脉储层压力、波强分析和主动脉功能指数，研究了严重主动脉瓣狭窄患者 TAVR 后即刻测量的左心室和中心主动脉压力的变化。共纳入 54 例患者（平均年龄 83.6±6.2 岁，50.0%为女性），进行 TAVR。我们对 TAVR 前后即刻从升主动脉和左心室获得的有创压力波形进行了储层压力和波强分析。TAVR 后，收缩压、舒张压、平均压和脉搏压均升高（均<0.05）。TAVR 后储层压力无变化（54.5±12.4 与 56.6±14.0 mm Hg，=0.30），但过量压力增加 47%（29.0±10.9 与 42.6±15.5 mm Hg，<0.001）。波强分析（任意单位，au）显示，前向压缩波增加（64.9±35.5 与 124.4±58.9，×10 au，<0.001），后向压缩波增加（11.6±5.5 与 14.4±6.9，×10 au，=0.01），前向扩张波能量增加（43.2±27.3 与 82.8±53.1，×10 au，<0.001）。TAVR 后，心内膜下活力比改善，主动脉功能基本不变。TAVR 后中心主动脉压升高与向近端主动脉传递的功率和能量增加有关，过量压力增加，但储层压力不变。这些变化为 TAVR 后相对高血压与改善预后相关提供了潜在机制。
