Roberto Scarsini; Emanuele Gallinoro; Marco  B. Ancona; Leonardo Portolan; Pasquale Paolisso; Paolo Springhetti; Francesco Della Mora; Andrea Mainardi; Marta Belmonte; Francesco Moroni; Luca  A. Ferri; Barbara Bellini; Filippo Russo; Ciro Vella; Dario  Tino Bertolone; Gabriele Pesarini; Giovanni Benfari; Marc Vanderheyden; Matteo Montorfano; Bernard De Bruyne; Emanuele Barbato; Flavio Ribichini

doi:10.4244/EIJ-D-23-00735

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

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

Abstract

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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