CTO lesions tied to in-hospital complications during, after TAVR
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Patients who undergo transcatheter aortic valve replacement with concomitant chronic total occlusion lesions experience more periprocedural complications compared with those without CTO, but are not at increased mortality risk, data show.
“A growing body of literature suggests that coronary CTOs are associated with adverse outcomes and increased mortality in CAD populations,” Maximilian Will, MD, of the Karl Landsteiner Institute for Cardiometabolics in St. Poelten, Austria, and colleagues wrote in Catheterization and Cardiovascular Interventions. “Several underlying mechanisms for these findings were postulated and may also apply to patients undergoing TAVR. However, most randomized controlled trials and large registries that investigated TAVR outcomes lack detailed information regarding patients with complex CAD and coronary CTOs. Thus, evidence concerning the prognostic relevance of a CTO in TAVR patients is sparse.”
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In a systematic review and meta-analysis, Will and colleagues assessed four studies evaluating 25,432 patients who underwent TAVR, with outcomes stratified based on presence of coronary CTO. The mean age across studies was 80 years; mean follow-up ranged from in-hospital outcomes to 8 years. One study was an analysis of 2016 national records in the U.S., whereas the others were single-center studies. The researchers performed a pooled analysis to estimate the rate and risk ratio for mortality.
Across three studies that assessed CAD status, the rate varied from 67.8% to 75.5% of patients; the prevalence of CTO varied between 2% and 12.6%.
Researchers found that, compared with no CTO, the presence of CTO was associated with an increase in hospital length of stay (mean, 8.1 days vs. 5.9 days; P < .01), cardiogenic shock (5.1% vs. 1.7%; P < .01), acute MI (5.8% vs. 2.8%; P = .02) and acute kidney injury (18.6% vs. 13.9%; P = .048).
The pooled 1‐year death rate was 24.8% in the CTO group and 23.8% among patients with no CTO. The meta‐analysis of death with CTO compared with no CTO showed a nonsignificant trend toward increased mortality with the presence of CTO, with a risk ratio of 1.11 (95% CI, 0.9-1.4; I2 = 0%).
“The results of the current review may suggest that if a patient is fit enough to undergo TAVR, then he or she would be fit enough to survive discharge irrespective of the presence of CTO even if they have longer length of stay and have in‐hospital adverse complications,” the researchers wrote. “Unsurprisingly, long‐term mortality is not different in patients with CTO undergoing TAVR because life expectancy is naturally limited in this frail elderly population. This may introduce a bias related to high rates of mortality in both groups which shifts the long‐term outcomes toward no difference between groups.”
The researchers noted that the decision to undertake CTO PCI and TAVR “may not be a straightforward decision” and a heart multidisciplinary team is needed.
“This reflects the difference in centers and experience of operators,” the researchers wrote. “Nevertheless, larger studies are needed, ideally a randomized controlled trial. Randomization is important to eliminate the selection bias effect.”
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