Abstract
Background/AimDegenerative aortic valve stenosis (AS) is associated to ventricular arrhythmias and sudden cardiac death, as well as mental stress in specific patients. In such a context, substrate, autonomic imbalance as well as repolarization dispersion abnormalities play an undoubted role. Aim of the study was to evaluate the increase of premature ventricular contractions (PVC) and complex ventricular arrhythmias during mental stress in elderly patients candidate to the transcatheter aortic valve replacement (TAVR).MethodsIn eighty-one elderly patients with AS we calculated several short-period RR- and QT-derived variables at rest, during controlled breathing and during mild mental stress, the latter being represented by a mini-mental state evaluation (MMSE).ResultsAll the myocardial repolarization dispersion markers worsened during mental stress (p < 0.05). Furthermore, during MMSE, low frequency component of the RR variability increased significantly both as absolute power (LFRR) and normalized units (LFRRNU) (p < 0.05) as well as the low-high frequency ratio (LFRR/HFRR) (p < 0.05). Eventually, twenty-four (30%) and twelve (15%) patients increased significantly PVC and, respectively, complex ventricular arrhythmias during the MMSE administration. At multivariate logistic regression analysis, the standard deviation of QTend (QTesd), obtained at rest, was predictive of increased PVC (odd ratio: 1.54, 95% CI 1.14–2.08; p = 0.005) and complex ventricular arrhythmias (odd ratio: 2.31, 95% CI 1.40–3.83; p = 0.001) during MMSE. The QTesd showed the widest sensitive-specificity area under the curve for the increase of PVC (AUC: 0.699, 95% CI: 0.576–0.822, p < 0.05) and complex ventricular arrhythmias (AUC: 0.801, 95% CI: 0.648–0.954, p < 0.05).ConclusionIn elderly with AS ventricular arrhythmias worsened during a simple cognitive assessment, this events being a possible further burden on the outcome of TAVR. QTesd might be useful to identify those patients with the highest risk of ventricular arrhythmias. Whether the TAVR could led to a QTesd reduction and, hence, to a reduction of the arrhythmic burden in this setting of patients is worthy to be investigated.
Highlights
Senile degenerative aortic valve stenosis (AS) represents the most relevant valvular heart disease both in terms of prevalence and of prognostic implications in Western countries
Receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of studied parameters predictive of complex ventricular arrhythmias and areas under ROC curves and 95% confidence intervals (CI) were calculated to compare the diagnostic efficiencies
Supporting the abovementioned hypothesis, we found a significant increase in the explored sympathetic markers at RR power spectral analysis (Task Force of the European Society of Cardiology, and the North American Society of Pacing, and Electrophysiology, 1996; Piccirillo et al, 2009b, 2016) as well a significant reduction in two well-known vagal markers (Robbe et al, 1987; Pagani et al, 1988; Piccirillo et al, 2000a,b, 2004b, 2013, 2016)
Summary
Senile degenerative aortic valve stenosis (AS) represents the most relevant valvular heart disease both in terms of prevalence and of prognostic implications in Western countries. A mainly neglected factor possibly impacting the AS patients prognosis is represented by their propensity to the malignant arrhythmias. Sympathetic over-activity, typical in chronic heart failure, could play an important role as malignant ventricular arrhythmias’ trigger. In such a context, there are two previous observations corroborating these claims: it was recently confirmed that the sudden cardiac death during AS remains statistically important (Minamino-Muta et al, 2017) and, some non-invasive electrocardiographic (ECG) markers were found significantly associated to a poor outcome in elderly patients with AS after the transcatheter aortic valve replacement (TAVR) (Piccirillo et al, 2018)
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