Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement

Abstract

Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.

Keywords

surgical aortic valve replacement / trans-catheter aortic valve implantation / left ventricular hypertrophy and fibrosis / myocardial force-velocity relationship / His-Purkinje pacing / renin-angiotensin system inhibitors / coronary access impairment

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Acknowledgements

The authors received financial support for the research work in cardiac physiology and aortic valve surgery by research grant from Garfield Weston Trust, London (to Xu Yu Jin and John R Pepper) and from Oxford Hospital Charity, Oxford (to Xu Yu Jin).

Compliance with ethics guideline

Xu Yu Jin, Mario Petrou, Jiang Ting Hu, Ed D Nicol, and John R Pepper declared no potential conflict of interests with respect to the research, authorship and/or publication of this article. This manuscript is a review article and does not involve a research protocols requiring approval by the relevant institutional review board of ethics committee.

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