Integrated remodeling dynamics and early physiologic recovery predict outcomes after transcatheter aortic valve replacement
R Wimolwattanaphan, A Tunhasiriwet, P Rawangban, C Wuttichaipradit, N Sririsreetreerux, C Wongsinkongman, V Muangsillapasart, W LuangphiphatAbstract
Background
Although transcatheter aortic valve replacement (TAVR) effectively relieves valvular obstruction, clinical outcomes remain heterogeneous. The prognostic role of early physiologic recovery and integrated post-procedural remodeling remains incompletely defined.
Objectives
To characterize temporal changes in myocardial mechanics after TAVR and determine whether early remodeling parameters independently predict major adverse cardiovascular events (MACE).
Methods
In 150 patients undergoing TAVR, speckle-tracking echocardiography was performed at baseline and at 3, 6, and 12 months to assess left ventricular global longitudinal strain (LVGLS) and left atrial reservoir strain (LASr). The prognostic cohort with complete clinical and imaging data at 6 months. Ventriculo-arterial coupling (VAC) was calculated non-invasively using echocardiographic volumes as the ratio of end-systolic volume to stroke volume (ESV/SV), reflecting ventricular–vascular interaction. Cox proportional hazards regression models were used to identify independent predictors of MACE, incorporating electrical substrate, residual afterload, myocardial recovery, and atrial reverse remodeling.
Results
The mean age was 80 ± 5 years, 54% were male, 12% had atrial fibrillation, and 68% had coronary artery disease. During a median follow-up of 3 years, 30 patients experienced MACE. Significant structural reverse remodeling occurred within 6 months, with left atrial volume index decreasing from 48 to 42 mL/m² (p < 0.001) and left ventricular mass index decreasing from 149 to 134 g/m² (p = 0.002). Both atrial and ventricular mechanics improved significantly after TAVR. LASr increased at 3 months (+1.92%, p = 0.031), 6 months (+4.44%, p < 0.001), and 12 months (+2.96%, p = 0.001). LVGLS improved at 3 months (+2.32%, p < 0.001), 6 months (+3.04%, p < 0.001), and 12 months (+3.28%, p < 0.001), with most recovery occurring within 6 months and subsequent plateau. Independent predictors of MACE included atrial fibrillation (HR 3.76, p = 0.0021), higher post-procedural VAC (HR 1.89, p = 0.0055), impaired LVGLS at 6 months (HR 0.84 per unit improvement, p = 0.0029), and absence of ≥10% reduction in left atrial volume (HR 2.69, p = 0.012).
Conclusions
Myocardial recovery after TAVR follows a time-dependent trajectory characterized by early structural and functional improvement with plateau after six months. Long-term outcomes are determined not only by procedural success but also by early physiologic recovery integrating electrical substrate, ventricular–vascular interaction, myocardial mechanics, and atrial reverse remodeling. Early remodeling parameters may improve post-TAVR risk stratification and guide individualized follow-up strategies.Remodeling GraphicFor image description, please refer to the figure legend and surrounding text.