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Changes and Prognostic Significance of Stroke Volume after Transcatheter Aortic Valve Replacement.
Henrique B. Ribeiro, Florent Le Ven, Christophe Thébault, Abdelaziz Dahou, Romain Capoulade, Haifa Mahjoub, Marina Urena, Luis Nombela-Franco, Ricardo Allende, Marie-Annick Clavel, Éric Dumont, Robert DeLarochellière, Daniel Doyle, Josep Rodés-Cabau, Philippe Pibarot.
Quebec Heart & Lung Institute, Quebec, QC, Canada.

Background: The presence of low LV outflow, i.e. reduced stroke volume index (SVi), prior to the procedure has been recently shown to be a powerful independent predictor of early and late mortality in high-risk patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). The objectives of this study were to examine changes in flow (i.e. SVi) occurring after TAVR, their determinants and the impact of post-procedural SVi (PP-SVi) on mortality. Methods: We retrospectively analyzed the clinical, Doppler-echocardiographic, and outcome data prospectively collected in 255 patients who underwent TAVR for symptomatic severe AS. Echocardiograms were performed before (baseline), within 5 days after procedure (post-procedural) and 6 months to 1 year following TAVR (late-FU). Results: Post-TAVR echocardiographic data were available in 255 (89%) patients. Mean follow-up was 18 ± 15 months. Patients with early post-procedural SVi (PP-SVi) <35ml/m² (n=138; 54%) had increased mortality (HR: 1.97, p =0.003) compared to those with PP-SVi >35 ml/m² (n=117; 46%). Furthermore, patients with baseline (pre-procedural) SVi (B-SVi) <35ml/m² and PP-SVI >35ml/m², i.e. with normalized flow, had better survival (HR: 0.46, p=0.03) than those with both B-SVi and PP-SVi <35ml/m², i.e persistent low-flow, and similar survival compared to those with both B-SVi and PP-SVi >35 ml/m², i.e. maintained normal flow. In a multivariable model adjusted for gender, atrial fibrillation, trans-apical/transfemoral approach and post-procedural echo parameters (LVEF, mean gradient, pulmonary hypertension, moderate or severe aortic and mitral regurgitations), PP-SVi was independently associated with increased risk of mortality (HR 1.41 per 10 ml/m² decrease, p=0.03). The pre-procedural factors associated with PP-SVi <35 ml/m² were: atrial fibrillation (OR: 2.55, p=0.01), trans-apical approach (OR: 2.46, p=0.002), mean transvalvular gradient (OR: 1.22 per 10 mmHg decrease, p=0.05), and indexed aortic valve area (OR: 1.67 per 0.1 cm²/m² decrease, p=0.02). Conclusion: The persistence of low-flow early after the procedure is an independent predictor of late mortality following TAVR.

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