Original title: Predictive factors of early mortality after transcatheter aortic valve implantation: individual risk assessment using a simple escore. Reference: Heart. 2014 Apr 16. doi: 10.1136/heartjnl-2013-305314. Epub ahead of print.
The decision to perform an intervention in symptomatic aortic stenosis must balance surgery or transcatheter aortic valve implantation (TAVI) risk. Factors associated with early mortality after TAVI with the aim to develop and validate a simple risk score were identified.
A population of 3833 consecutive patients was randomly divided into two groups comprising 2552 and 1281 patients, respectively, used to develop and validate a scoring system to predict hospital and 30 days mortality. TAVI was performed using the Edwards Sapien prosthesis in 2551 (66.8 %) patients and the Medtronic CoreValve in 1270 (33.2 %). The implant was transfemoral in 2801 (73.4 %) patients, transapical in 678 (17.8%), subclavian in 219 (5.7%) and others in 117 (3.1%). Early mortality was 10.0 % (382 patients). A multivariate logistic model identified the following predictors of early mortality: age ≥ 90 years ; BMI
|
|
OR (IC 95%) |
p |
Score |
|
Critical conditiona |
2.39 (1.42 to 4.02) |
0.001 |
3 |
|
Low BMI, ≤18.5 kg/m2 |
2.27 (1.09 to 4.74) |
0.03 |
3 |
|
Respiratory failure |
1.64 (1.22 to 2.20) |
0.001 |
2 |
|
Dialysis |
2.88 (1.46 to 5.66) |
0.002 |
4 |
|
Trans apical access |
2.02 (1.47 to 2.78) |
< 0.0001 |
2 |
|
Other no femoral access |
2.18 (1.11 to 4.28) |
0.02 |
3 |
a) Defined as any of the following situations including , ventricular tachycardia , preoperative cardiac massage or acute kidney failure.
Conclusion
Early mortality after TAVI is mainly related to age, severity of symptoms, comorbidities and transapical access. A simple score can be used to predict early mortality after TAVI.
Editorial Review
A well-validated score is important and necessary to predict postoperative mortality after TAVI. This process is proving to be increasingly safe and reliable, but the analysis of this record (perhaps one of the most important and detailed of the world), put precise numbers on patients in whom this treatment is not going to affect the quality of life or even might not be useful. TAVI in acute patients with significant malnutrition appears to be extremely risky and probably in this sub-group, the beneficial effect of the method is diluted. Another significant point is that actually a different access than the transfemoral changes technic results. At this point, I think the results are yet impacted by the learning curve and close access to the cardiac apex.
Courtesy Matías Sztejfman MD.
Interventional Cardiologist.
Sanatorio Güemes.
Buenos Aires, Argentina.
Dr. Matías Sztejfman