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Observational Study
. 2024 Mar 4;20(5):e289-e300.
doi: 10.4244/EIJ-D-23-00735.

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

Roberto Scarsini  1 , Emanuele Gallinoro  2   3 , Marco B Ancona  4 , Leonardo Portolan  1 , Pasquale Paolisso  2   5 , Paolo Springhetti  1 , Francesco Della Mora  1 , Andrea Mainardi  1 , Marta Belmonte  2   5 , Francesco Moroni  4 , Luca A Ferri  4 , Barbara Bellini  4 , Filippo Russo  4 , Ciro Vella  4 , Dario Tino Bertolone  2   5 , Gabriele Pesarini  1 , Giovanni Benfari  1 , Marc Vanderheyden  2 , Matteo Montorfano  4   6 , Bernard De Bruyne  2 , Emanuele Barbato  7 , Flavio Ribichini  1
Affiliations
Observational Study

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

Roberto Scarsini et al. EuroIntervention. .

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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Conflict of interest statement

R. Scarsini reports research grant from Abbott and Philips; and speaker fees from Abbott. F. Ribichini reports research grant from Abbott and Philips. P. Paolisso, M. Belmonte, and D.T. Bertolone are supported by a research grant from the CardioPaTh PhD Program. E. Barbato declares speaker fees from Abbott, Boston Scientific, and GE HealthCare. B. De Bruyne has received consultancy fees from Boston Scientific and Abbott; research grants from Coroventis Research, Pie Medical Imaging, CathWorks, Boston Scientific, Siemens, HeartFlow, and Abbott; and owns equity in Siemens, GE HealthCare, Philips, HeartFlow, Edwards Lifesciences, Bayer, Sanofi, and Celiad. M.B. Ancona received consultant fees from Abbott and Abiomed. M. Montorfano is a proctor for Abbott, Kardia, and Boston Scientific. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1. Definition of extravalvular cardiac damage.
Généreux extravalvular cardiac damage (EVCD) classification was dichotomised into stages 0-2 (isolated left heart dysfunction) and stages 3-4 (advanced extravalvular cardiac damage with right heart involvement). LAVI: left atrial volume index; LV: left ventricular; LVEF: left ventricular ejection fraction; MR: mitral regurgitation; RV: right ventricular; sPAP: systolic pulmonary arterial pressure; TAPSE: tricuspid annular plane systolic excursion; TR: tricuspid regurgitation
Figure 2
Figure 2. Coronary physiology data in patients with LF LG-AS versus NF HG-AS.
Coronary microvascular function expressed by MRR (A), CFR (B) and RRR (C) was significantly impaired in patients with LF LG-AS compared with those with NF HG-AS. FFR was significantly lower in patients with NF HG-AS (D). CFR: coronary flow reserve; FFR: fractional flow reserve; LF LG-AS: low-flow low-gradient aortic stenosis; MRR: microvascular resistance reserve; NF HG-AS: normal-flow high-gradient aortic stenosis; RRR: resistive reserve ratio; TAVI: transcatheter aortic valve implantation
Figure 3
Figure 3. Predictors of low pre-TAVI microvascular resistance reserve.
The multivariable logistic regression model including female gender, eGFR CG <60 ml/min, advanced EVCD (Généreux stages 3-4) and low-flow phenotype (SVi <30 ml/min) demonstrated good accuracy in predicting a low MRR. aOR: adjusted odds ratio; AUC: area under curve; CI: confidence interval; eGFR CG: estimated glomerular filtration rate (Cockcroft-Gault method); EVCD: extravalvular cardiac damage; MRR: microvascular resistance reserve; ROC: receiver operating characteristic; SVi: stroke volume index; TAVI: transcatheter aortic valve implantation
Formule 1
Formule 1
Formule 1
Central illustration
Central illustration. Coronary physiology data stratified according to extravalvular cardiac damage
Coronary microvascular function expressed by MRR (A) and RRR (C) was significantly impaired in patients with advanced extravalvular cardiac damage. CFR and FFR were not significantly different between patients with and without advanced extravalvular cardiac damage (B and D). CFR: coronary flow reserve; FFR: fractional flow reserve; MRR: microvascular resistance reserve; RRR: resistive reserve ratio; TAVI: transcatheter aortic valve implantation
See this image and copyright information in PMC

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