Vitez Luka, Starc Vito, Jug Borut, Bunc Matjaž
Department of Cardiology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia.
Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia.
Rev Cardiovasc Med. 2023 May 8;24(5):140. doi: 10.31083/j.rcm2405140. eCollection 2023 May.
Degenerative aortic stenosis is an atherosclerotic-like process associated with impaired endothelial and autonomic function. Transcatheter aortic valve implantation (TAVI) has become a treatment of choice for patient with severe degenerative aortic stenosis at high surgical risk. The effect of this procedure on endothelial function measured with flow mediated dilatation (FMD) and autonomic function measured with heart rate variability (HRV) at different time-points of disease management (early and late follow-up) remains unknown.
We prospectively included 50 patients with severe aortic stenosis who were deemed suitable for TAVI by the Heart Team. FMD and HRV parameters were collected at baseline ( 24 h pre-TAVI), at early follow-up (up to 48 h post-TAVI) and at late follow-up (3-6 months post-TAVI).
43 patients (mean age 81 (75-85); 60% women) completed the study. FMD significantly improved from 2.8 1.5% before TAVI to 4.7 2.7% early after TAVI ( 0.001) and was later maintained on late follow-up (4.8 2.7%, = 0.936). Conversely, high-resolution ECG parameters remained preserved at early and improved at late follow-up after TAVI. Significant improvement was detected in a high frequency-domain parameter-HF (from 5231 1783 to 6507 1789 ; = 0.029) and in two Poincare plot parameters: ratio of the short- and long-term R-R variability in the Poincare plot-SD1/SD2 (from 0.682 to 0.884 ; = 0.003) and short-term R-R variability in the Poincare plot-SDRR (from 9.6 to 23.9 ms; = 0.001). Echocardiographic parameters comprising baseline maximal aortic valve velocity (R = 0.415; = 0.011), mean aortic gradient (R = 0.373; = 0.018), indexed stroke volume (R = 0.503; = 0.006), change in aortic valve maximal velocity (R = 0.365; = 0.031), change in mean aortic gradient (R = 0.394; = 0.019) and NT-proBNP (R = 0.491; = 0.001) were found as significant predictors of change in FMD.
Endothelial function measured with FMD and autonomic function obtained with HRV parameters significantly improve after TAVI. While endothelial function improves early and is maintained later after TAVI, autonomic function remains stable and improves on late follow-up. This is most likely caused by early hemodynamic changes after resolution of aortic valve obstruction and gradual left ventricular remodeling.
www.clinicaltrials.gov, identifier NCT04286893.
退行性主动脉瓣狭窄是一种与内皮功能和自主神经功能受损相关的动脉粥样硬化样病变。经导管主动脉瓣植入术（TAVI）已成为手术风险高的重度退行性主动脉瓣狭窄患者的首选治疗方法。该手术对疾病管理不同时间点（早期和晚期随访）通过血流介导的血管舒张（FMD）测量的内皮功能以及通过心率变异性（HRV）测量的自主神经功能的影响尚不清楚。
我们前瞻性纳入了50例经心脏团队评估适合TAVI的重度主动脉瓣狭窄患者。在基线（TAVI术前24小时）、早期随访（TAVI术后48小时内）和晚期随访（TAVI术后3 - 6个月）收集FMD和HRV参数。
43例患者（平均年龄81岁（75 - 85岁）；60%为女性）完成了研究。FMD在TAVI术前为2.8±1.5%，术后早期显著改善至4.7±2.7%（P<0.001），晚期随访时维持在该水平（4.8±2.7%，P = 0.936）。相反，高分辨率心电图参数在TAVI术后早期保持不变，并在晚期随访时改善。在高频域参数 - HF（从5231±1783至6507±1789；P = 0.029）以及两个庞加莱图参数中检测到显著改善：庞加莱图中短期和长期R - R变异性的比值 - SD1/SD2（从0.682至0.884；P = 0.003）和庞加莱图中短期R - R变异性 - SDRR（从9.6至23.9毫秒；P = 0.001）。包括基线主动脉瓣最大流速（R = 0.415；P = 0.011）、平均主动脉瓣压差（R = 0.373；P = 0.018）、每搏量指数（R = 0.503；P = 0.006）、主动脉瓣最大流速变化（R = 0.365；P = 0.031）、平均主动脉瓣压差变化（R = 0.394；P = 0.019）和N末端B型利钠肽原（R = 0.491；P = 0.001）在内的超声心动图参数被发现是FMD变化的显著预测因素。
TAVI术后，通过FMD测量的内皮功能和通过HRV参数获得的自主神经功能显著改善。虽然内皮功能在TAVI术后早期改善并在后期维持，但自主神经功能在早期保持稳定并在晚期随访时改善。这很可能是由于主动脉瓣梗阻解除后的早期血流动力学变化以及逐渐的左心室重构所致。
