Bleeding and Mortality in Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is much less invasive than surgical replacement. This is associated with a substantial reduction in bleeding events (up to 60% less).

However, clinically relevant bleeding is still present in one every four patients who undergo TAVR, which is associated with morbidity and mortality.

Cases of bleeding are not uniform: they may be associated with the access site and observed during the peri-procedural period, or be entirely unrelated to access and observed during a longer follow-up.

Also read: “Incomplete Revascularization Is Associated with Mortality in TAVR.”

Before this work, we did not know whether the bleeding site could affect prognosis differently in patients who undergo TAVR.

In total, 926 consecutive patients treated from 2007 through 2014 were evaluated with up to 5 years of follow-up.

A total of 285 patients (30.7%) experienced some kind of bleeding (minor, major, or life-threatening). Compared with patients not experiencing bleeding, the risk for all-cause mortality was significantly increased among patients with access-site-related bleeding (hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 1.01 to 1.76; p = 0.04) and was even higher among patients with non-access-site-related bleeding (HR: 2.08; 95% CI: 1.60 to 2.71; p <0.001).

Also read: “Bivalirudin Reduces Bleeding Rate in Carotid Stenting.”

At multivariate analysis, female sex was associated with access-site bleeding, whereas renal insufficiency and the Society of Thoracic Surgeons (STS) score were significantly associated with non–access-site bleeding.

Conclusion

Among patients with severe aortic stenosis undergoing transcatheter aortic valve replacement, bleeding was independently associated with an increased risk of mortality. Non-access-site bleeding appeared to be the most dangerous type.

Editorial

The percentage for both types of bleeding was practically the same (51% vs. 49%), but 40% of all cases of non-access-site bleeding were experienced beyond the first 30 days after the procedure, and were associated with a risk of mortality 1.5 times higher than that for access-site bleeding.

This finding is similar to that observed for coronary angioplasty, for which non-access-site bleeding is also more dangerous.

Reasons are multifactorial, but non-access-site bleeding is generally experienced by patients with a higher-risk profile due to comorbidities.

Original title: Frequency, Timing, and Impact of Access-Site and Non–Access-Site Bleeding on Mortality Among Patients Undergoing Transcatheter Aortic Valve Replacement.

Reference: Raffaele Piccolo et al. J Am Coll Cardiol Intv 2017;10:1436-46.

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