Characterisation of coronary microvascular dysfunction in patients with severe aortic stenosis undergoing TAVI

DOI: 10.4244/EIJ-D-23-00735

Roberto Scarsini
Roberto Scarsini1, MD, PhD; Emanuele Gallinoro2,3, MD, PhD; Marco B. Ancona4, MD; Leonardo Portolan1, MD; Pasquale Paolisso2,5, MD; Paolo Springhetti1, MD; Francesco Della Mora1, MD; Andrea Mainardi1, MD; Marta Belmonte2,5, MD; Francesco Moroni4, MD; Luca A. Ferri4, MD; Barbara Bellini4, MD; Filippo Russo4, MD; Ciro Vella4, MD; Dario Tino Bertolone2,5, MD; Gabriele Pesarini1, MD, PhD; Giovanni Benfari1, MD, PhD; Marc Vanderheyden2, MD; Matteo Montorfano4,6, MD; Bernard De Bruyne2, MD, PhD; Emanuele Barbato7, MD, PhD; Flavio Ribichini1, MD
1. Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy; 2. Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; 3. Division of University Cardiology, IRCCS Galeazzi - Sant’Ambrogio Hospital, Milan, Italy; 4. Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; 5. Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy; 6. School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; 7. Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy

Background: Microvascular resistance reserve (MRR) is a validated measure of coronary microvascular function independent of epicardial resistances.

Aims: We sought to assess whether MRR is associated with adverse cardiac remodelling, a low-flow phenotype and extravalvular cardiac damage (EVCD) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

Methods: Invasive thermodilution-based assessment of the coronary microvascular function of the left anterior descending artery was performed in a prospective, multicentre cohort of patients undergoing TAVI. Coronary microvascular dysfunction (CMD) was defined as the lowest MRR tertile of the study cohort. Haemodynamic measurements were performed at baseline and then repeated immediately after TAVI. EVCD and markers of a low-flow phenotype were assessed with echocardiography.

Results: A total of 134 patients were included in this study. Patients with low MRR were more frequently females, had a lower estimated glomerular filtration rate and a higher rate of atrial fibrillation. MRR was significantly lower in patients with advanced EVCD (median 1.80 [1.26-3.30] vs 2.50 [1.87-3.41]; p=0.038) and in low-flow, low-gradient AS (LF LG-AS) (median 1.85 [1.20-3.04] vs 2.50 [1.87-3.40]; p=0.008). Overall, coronary microvascular function tended to improve after TAVI and, in particular, MRR increased significantly after TAVI in the subgroup with low MRR at baseline. However, MRR was significantly impaired in 38 (28.4%) patients immediately after TAVI. Advanced EVCD (adjusted odds ratio 3.08 [1.22-7.76]; p=0.017) and a low-flow phenotype (adjusted odds ratio 3.36 [1.08-10.47]; p=0.036) were significant predictors of CMD.

Conclusions: In this observational, hypothesis-generating study, CMD was associated with extravalvular cardiac damage and a low-flow phenotype in patients with severe AS undergoing TAVI.

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