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Transapical, transfemoral TAVR feasible for patients with aortic stenosis, chronic liver disease
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In patients with aortic stenosis and concomitant mild-to-moderate chronic liver disease, transapical and transfemoral transcatheter aortic valve replacement appear to be feasible, researchers reported in a recent study.
Researchers evaluated records of 706 patients with aortic stenosis (mean age, 77 years; 10 men) who underwent balloon-expandable transapical or transfemoral TAVR (Sapien or Sapien XT, Edwards Lifesciences) at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center from November 2007 to February 2014.
Liver biopsy revealed that 17 patients (2.41%) had chronic liver disease. Of those, 14 received transfemoral TAVR and three received transapical TAVR.
Model for end-stage liver disease (MELD) scores ranged from 6 to 19 (mean, 11.35). Eleven patients were classified as Child-Turcotte-Pugh class A and six as Child-Turcotte-Pugh class B.
Safety and efficacy endpoints included device success; in-hospital and 30-day mortality; MI; acute kidney injury; bleeding; transfusion > 1 U of packed red cells; vascular complications; stroke; and permanent pacemaker placement.
Mean patient follow-up was 466 days (range, 12-1,403).Mean hospital length of stay after TAVR was 5.88 ± 3.08 days. In all cases, the procedure was successful.
The rate of in-hospital mortality was 5.88% and the rate of 90-day mortality was 17.65%.
Valve Academic Research Consortium (VARC)-defined safety and efficacy endpoints were significant for one death from a proximate cardiac cause on postoperative day 14 in a patient who died of post-implantation congestive HF; one death due to unknown causes on postoperative day 12 (three days after hospital discharge); one late death due to sepsis and acute liver injury in a patient with history of liver transplant and immunosuppression (Child-Turcotte-Pugh class A; MELD score, 15; biopsy-confirmed chronic hepatitis) on postoperative day 50; one late death due to sepsis and renal failure on postoperative day 487; and one late death due to unknown causes on postoperative day 1,005, according to the results.
The researchers reported no life-threatening or major bleeding complications. There was one case of periprocedural MI and one case of transient ischemic attack.
Sustained transient stage 1 acute kidney injury occurred in four patients, and sustained transient stage 2 acute kidney injury occurred in one patient.
No patients required permanent pacemaker implantation after the procedure.
“There remains a dearth of information on the outcomes of patients with chronic liver disease and concomitant severe aortic stenosis undergoing TAVR. The current report represents the largest analysis to date of this unique, high-risk population,” the researchers wrote. “… Outcomes in patients with advanced liver disease warrant further study. Additionally, liver disease should be taken into consideration when developing a TAVR-specific risk scoring system.” – by Jennifer Byrne
Disclosure: Several researchers report financial ties with Edwards Lifesciences. See the full study for a list of the authors’ relevant financial disclosures.
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