Ageing, hypertension and aortic valve stenosis: understanding the series circuit using cardiac magnetic resonance and applanation tonometry

Background: Aortic stenosis (AS) is no longer considered to be a disease of fixed left ventricular (LV) afterload, but rather, functions as a series circuit, with important contributions from both the valve and vasculature. Patients with AS are typically elderly, with hypertension and a markedly remodelled aorta. The arterial component is sizeable, and yet, quantifying this to-date has been difficult to determine. We compared measurement of aortic pressure, flow and global LV load using a cardiac magnetic resonance (CMR)/applanation tonometry (AT) technique to uncouple ventriculo-arterial (VA) interactions. Methods: 20 healthy elderly patients and 20 with AS underwent a CMR/AT protocol. CMR provided LV volume and aortic flow simultaneously with AT pressure acquisition. Aortic pressure was derived by transformation of the AT waveform. Systemic vascular resistance (SVR) and global LV load were determined as the relationship of pressure to flow in the frequency domain. Values from both cohorts were compared. Results: AS patients were older (p ​< ​0.01) albeit with no significant difference in brachial or central aortic pressure. SVR (14228 vs 19906 ​dyne ​s.cm⁻³; p ​= ​0.02) and load (740 vs 946 ​dyne ​s.cm⁻³; p ​= ​0.02) were higher in patients with AS, whilst aortic peak flow velocity was lower (38 vs 58 ​cm/s; p ​< ​0.01). Conclusions: Quantification of aortic pressure, flow velocity and global LV load using a simultaneous CMR/AT technique is able to demonstrate the progressive effects of hypertension and aortic stiffening with advanced age and valvular stenosis. This technique may help to better identify future patients at risk of VA coupling mismatch after correction of AS.