Reverse remodeling after TAVR

Does RAAS blockade help?

As we know, patients with senile aortic stenosis may present an increase in afterload and subject or left ventricle to high stress that generates an adaptation with hypertrophy, applied in Laplace’s law. In more advanced situations, we can have an imbalance of this adaptation and start a process of apoptosis of myocytes, as well as interstitial fibrosis that lead to the loss of potential contractile and applications or increase in severe arrhythmias.

Some individuals experience a reverse remodeling after TAVR simply by reducing the afterload, but little is known which ones will show this evolution and to what degree of fibrosis we can expect some reversion.

In heart failure, with a drop in the ejection fraction, there is a number of drugs that act to protect myocardium by reducing interstitial fibrosis, such as the blockers of the renin-angiotensin aldosterone system (RAAS).

Do these drugs have any benefit in the long-term follow-up of patients undergoing TAVR?

However physiologically it makes sense, this should be an analysis with many biases, as patients undergoing TAVR in general are full of other comorbidities that could benefit from the use of these medication classes and hinder the specific analysis of aortic stenosis.

However, a database analysis of several European institutions showed us that the use of RAAS blockers after TAVR was an independent predictor of lower cardiovascular mortality in the medium term, not of general mortality. It also showed that those who used doses of angiotensin receptor blockers or angiotensin-converting enzyme inhibitors at hospital discharge had more left ventricular reverse remodeling with a reduction in both diameters and ventricular mass.

The analysis also showed that users of these drugs had a lower incidence of atrial fibrillation, cerebrovascular events and hospital readmissions due to decompensated heart failure.

The hemodynamic repercussion in aortic stenosis is so related to the prognosis that there is even a classification of severity of aortic stenosis based on these changes as we saw recently here on thevalveclub platform. Nevertheless, intervening in these issues after the intervention procedure seems to have some benefit in the clinical evolution in these cases.

It is worth mentioning that, to date, no work has evaluated the impact of the famous sacubitril-valsartan association that is so evident in patients with heart failure, which may bring us even more data on the evolutionary profile of RAAS in this group of patients.

Suggested literature:

1 – Rodriguez-Gabella T, Catalá P, Muñoz-García AJ, et al. Renin-Angiotensin System Inhibition Following Transcatheter Aortic Valve Replacement. J Am Coll Cardiol. 2019 Aug 6;74(5):631-641.

 

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