Advanced HF, SCD most common cardiac causes of post-TAVR mortality

In a new study, advanced HF and sudden cardiac death accounted for two-thirds of cardiac-related deaths after transcatheter aortic valve replacement.

Few studies have investigated predictors and the burden of cardiac mortality after TAVR. Researchers for the current study investigated the incidence and predictors of cardiac mortality related to advanced HF and sudden cardiac death in 3,726 patients who underwent TAVR at 18 centers in Europe, North America and South America. Fifty-seven percent of patients received a balloon-expandable valve and 43% a self-expandable valve.

During an average follow-up of 22 months, 1,022 patients (27.4%) died. Of those, 336 (33%) were confirmed cardiac deaths. Advanced HF was the cause of death in 155 patients, which accounted for 15.2% of deaths in the overall cohort and 46.1% of cardiac deaths. The cumulative rate of death from advanced HF at 1 year was 2.9% (95% CI, 2.3-3.5) and at 2 year was 4.4% (95% CI, 3.7-5.2). Sudden cardiac death was the cause in 57 patients, which accounted for 5.6% of deaths in the overall cohort and 16.9% of cardiac deaths. The cumulative rate of sudden cardiac death at 1 year was 1% (95% CI, 0.6-1.4) and at 2 years was 1.8% (95% CI, 1.2-2.4).

Deaths related to advanced HF and sudden cardiac death were most frequent in the 6 months after TAVR, according to the researchers.

Independent predictors of mortality from advanced HF included:

chronic obstructive pulmonary disease at baseline (P < .05);
atrial fibrillation at baseline (P < .05);
left ventricular ejection fraction ≤40% at baseline (P < .05);
low mean transaortic gradient (P < .05);
pulmonary artery systolic pressure >60 mm Hg (P < .05);
use of the transapical approach (HR = 2.38; 95% CI, 1.6-3.54; and
presence of moderate/severe aortic regurgitation after TAVR (HR = 2.79; 95% CI, 1.82-4.27).

Independent predictors of mortality from sudden cardiac death included LVEF ≤40% (HR = 1.93; 95% CI, 1.05-3.55) and new-onset persistent left bundle branch block (LBBB) after TAVR (HR = 2.26; 95% CI, 1.23-4.14). In addition, patients with new-onset persistent LBBB and a QRS duration longer than 160 ms had an increased risk for sudden cardiac death (HR = 4.78; 95% CI, 1.56-14.63).

“Future studies should evaluate whether specific therapeutic strategies targeting these factors … decrease these patients’ risk of cardiac death. In the meantime, our results allow identification of the patients at the highest risk of dying of HF or sudden cardiac death within the first months following TAVR and should contribute to improved clinical decision making,” the researchers wrote.

In an accompanying editorial, Thierry Lefèvre, MD, of the Institut Cardiovasculaire Paris Sud, noted that this study “sheds useful light on the risk of mortality from cardiac failure after TAVR, which, although substantial, is not ineluctable.”

According to Lefèvre, three key factors can be controlled in these patients: use of the transfemoral route, when feasible and safe; optimal valve sizing and positioning for prevention of paravalvular leak greater than one grade; and consideration of pacemaker implantation or cardiac resynchronization in patients with LBBB with large QRS width and impaired LV function, he wrote.

References:

Lefèvre T. J Am Coll Cardiol. 2015;doi:10.1016/j.jacc.2014.11.026.

Urena M, et al. J Am Coll Cardiol. 2015;doi:10.1016/j.jacc.2014.11.027.

Disclosure: The researchers report associations with companies including Abbott, Biotronik, CeloNova, Edwards Lifesciences, Medtronic, St. Jude Medical and Valtech Cardio.

Lefèvre has served as a proctor for Edwards Lifesciences and has received minor fees from Direct Flow, Medtronic and Symetis.