Endovascular Treatment of Flow-Limiting Iliofemoral Stenosis Improves Left Ventricular Diastolic Function in Patients With HFpEF by Reducing Aortic Pulsatile Load

Abstract

Background: Recent research indicates that there is a high prevalence of heart failure with preserved ejection fraction in patients with peripheral artery disease. We hypothesized that endovascular treatment (EVT) of flow-limiting peripheral stenosis improves left ventricular (LV) diastolic function.

Methods: Thirty patients with symptomatic peripheral artery disease and heart failure with preserved ejection fraction according to Heart Failure Association-preserved ejection fraction score who were scheduled for EVT or angiography were investigated at baseline, the day after EVT (n=25) or angiography (control, n=5), and at 4 months follow-up. Peripheral hemodynamics were determined by the total peripheral resistance, common femoral artery flow, and ankle brachial index. Aortic function was measured by arterial compliance, augmentation index, and pulse wave velocity. Aortic pulsatile load was estimated as the characteristic impedance of the proximal aorta and the magnitude of wave reflection (reflection coefficient). LV mass index, LV mean wall thickness, and systolic and diastolic function were assessed using echocardiography. Patient-centered outcomes were treadmill walking distance and New York Heart Association class.

Results: After EVT, peripheral hemodynamics changed significantly with a decrease in total peripheral resistance and an increase in common femoral artery flow and ankle brachial index. Aortic function improved after EVT, with significantly reduced augmentation index and pulse wave velocity and increased compliance immediately and at follow-up, resulting in a reduction in aortic pulsatile load (characteristic impedance of the proximal aorta and reflection coefficient). Concurrently, LV diastolic function improved after EVT compared with control, acutely and at follow-up, with increased septal and lateral e´ velocities and decreased E/e´ and left atrial volume index. The LV mass index and LV mean wall thickness decreased at follow-up. The New York Heart Association class and treadmill walking distance improved post-EVT at follow-up. Augmentation index, pulse wave velocity, and arterial compliance were identified as independent contributors to E/e´.

Conclusions: Endovascular treatment of flow-limiting iliofemoral stenosis reduces aortic pulsatile load and concurrently lowers total peripheral resistance. This beneficial effect is associated with an acute and sustained improvement of left ventricular diastolic function.

Registration: URL: http://www.clinicaltrials.gov; Unique identifier: NCT02728479.

Keywords: aorta; heart failure; peripheral arterial disease; pulse wave analysis; stroke volume.

Figure 1.

Overview of the study cohort, 3-element model of the aorta, and study protocol. A, CONSORT diagram. B, Three-element model of the aorta depicting parameters of inflow, aortic function, and peripheral hemodynamics. C, The study protocol. ABI indicates ankle brachial index; aBP, aortic blood pressure; AIx, augmentation index; AP, augmentation pressure; aPP, aortic pulse pressure; BP, blood pressure; CFA, common femoral artery; CKD, chronic kidney disease; CO, cardiac output; CONSORT, Consolidated Standards of Reporting Trials; HFpEF, heart failure with preserved ejection fraction; HR, heart rate; LVDF, left ventricular diastolic function; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; PWV, pulse wave velocity; RC, reflection coefficient; SV, stroke volume; TMWD, treadmill walking distance; TPR, total peripheral resistance; and Zc, characteristic impedance of the proximal aorta.

Figure 2.

Peripheral endovascular treatment (EVT) improves left ventricular diastolic function (LVDF). Functional and morphological changes in LVDF after EVT. Septal e´ (A), lateral e´ (B), E/e´ average (C), tricuspid regurgitation (TR; D), left atrial volume index (LAVI; E), LV mean wall thickness (F), and LV mass index in female (LVMI; G) and male (H) patients before (circle), after EVT (triangle), and at the follow-up (square) after elective EVT (n=25) or diagnostic angiography alone as a control (n=5). Unpaired t test was used to calculate P values.

Figure 3.

Reduction in NYHA class after endovascular treatment of flow-limiting iliofemoral stenosis. NYHA class (blue indicates NYHA I, orange indicates NYHA II, gray indicates NYHA III, and yellow indicates NYHA IV) at baseline before angioplasty (n=25) of flow-limiting stenosis and at follow-up. Wilcoxon signed-rank test was used to calculate P value. NYHA indicates New York Heart Association.