Extent of cardiac damage plays major role in quality of life after AVR
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BOSTON — In patients with aortic stenosis, a greater degree of cardiac damage before transcatheter or surgical aortic valve replacement increased the likelihood of poor quality of life outcomes after the procedure, researchers reported.
In addition, improvement in stage of cardiac damage after AVR was associated with better quality of life outcomes at 1 year compared with no change or worsening.
Degree of cardiac damage after TAVR or surgical AVR had previously been shown to be related to clinical outcomes 1 year after the procedure, Philippe Généreux, MD, co-director of the Structural Heart Program at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, said during a press conference at TCT 2022.
“In 2017, we presented this new concept of staging of aortic stenosis based on the extent of cardiac damage,” Généreux said during the press conference. “What we discovered is that the extent of cardiac damage at 1 year post-AVR was associated with mortality and adverse events, and that worsening of those stages from baseline to 1 year was associated with increased risk of death and repeat hospitalization at 2 years. What we don’t know is what is the impact of AVR and cardiac damage on quality of life.”
Généreux and colleagues analyzed 1,974 patients from the PARTNER trials who underwent TAVR with a balloon-expandable valve (Sapien family of products, Edwards Lifesciences) or surgical AVR and had complete aortic stenosis staging data based on echocardiography at baseline.
The patients were stratified into quintiles based on staging data at baseline: stage 0 (6.1%) indicated no damage, stage 1 (14.5%) indicated left ventricular damage, stage 2 (51.4%) indicated left atrial/mitral damage, stage 3 (20.9%) indicated pulmonary artery/tricuspid damage and stage 4 (7.1%) indicated right ventricular damage.
As the stage of baseline cardiac damage increased, baseline Kansas City Cardiomyopathy Questionnaire-Overall Summary Score (KCCQ-OS) worsened (P for trend < .0001), and the level of 1-year KCCQ-OS was lower (P for trend < .0001), though the stage 4 group had the largest improvement in KCCQ-OS at 1 year (P = .011), Généreux said during the press conference.
“The good news is that at 1 year, independently of your stage, you still had a benefit from AVR, whether TAVR or surgery,” he said. “But what we saw is that as you increase the extent of cardiac damage, you increase the rate of poor outcomes related to health status.”
At 1 year, the higher the stage of baseline cardiac damage, the more likely a patient was to die, have a KCCQ-OS less than 60 or experience the composite of death, KCCQ-OS less than 60 or decline in KCCQ-OS of at least 10 (P < .0001 for all), according to the researchers. There was no relationship between stage of baseline cardiac damage and decline in KCCQ-OS of at least 10 at 1 year (P = .76).
In a multivariate model, each 1-stage increase in baseline cardiac damage conferred a 24% increased risk for a poor health status outcome (OR = 1.24; 95% CI, 1.09-1.41; P = .001).
Among the 1,120 patients with available echocardiograms at 1 year, cardiac damage stage was improved in 15.6%, unchanged in 57.9% and worsened in 26.5%, Généreux said.
Those with improvement in cardiac damage stage had the greatest improvement in KCCQ-OS at 1 year, followed by those with no change and then those with deterioration (+26.8 vs. +21.4 vs. +17.5; P for trend < .0001), he said.
“Evolution of cardiac damage had a real impact on quality of life at 1 year,” Généreux said during the press conference. “The regression of cardiac damage at 1 year was associated with greater health status improvement compared with patients whose cardiac damage was unchanged or worsened. We believe that detecting [aortic stenosis] aggressively before there is irreversible cardiac damage may help improve long-term outcomes after AVR. Longer follow-up is needed to characterize the impact of aortic stenosis and its stage on AVR and quality of life after it.”
Perspective
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Suzanne V. Arnold, MD, MHA
I was not surprised by these results. You would expect to see the unadjusted results showing greater improvement in the higher cardiac damage stages, simply due to them starting out with a lower KCCQ-OS, so when we account for baseline quality of life, we see less improvement at the higher stages. The magnitude of differences among the cardiac stages is also clearly relevant and expected as well.
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Généreux P, et al. Late-Breaking Clinical Science Session in Structural Heart Disease: Session IV, in Collaboration With the Journal of the American College of Cardiology. Presented at: TCT Scientific Symposium; Sept. 16-19, 2022; Boston (hybrid meeting).
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