Liver Failure as a Challenge for TAVR

Although surgical risk scores do not include liver failure (LF), patients who suffer from it and undergo cardiovascular surgery present high rates of morbidity and mortality. This is due to alteration of cardiac function, increased infection susceptibility, gastrointestinal complications, and increased bleeding.

As regards transcatheter aortic valve replacement (TAVR), these patients have not been included in most studies; in consequence, our information on it derives from small series or specific case reports.

This study analyzed 4876 patients who underwent TAVR, 114 of whom experienced LF.

LF patients tended to be younger (75 vs. 81 years old; p < 0.001) and most of them were male. Furthermore, they presented higher rates of chronic obstructive pulmonary disease (COPD), lower New York Heart Association functional class, higher gradient, and lower EuroSCORE_log.

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Propensity score matching was applied to make the sample more uniform, and it resulted in 114 patient pairs. The only difference was less transesophageal echocardiography monitoring for the LF group.

There were no differences as regards in-hospital mortality, stroke, major cardiovascular complications, major bleeding, life-threatening complications, and pacemaker implantation. The presence of kidney injury was higher among patients with LF (30.8% vs. 13.5%; p = 0.01). In-hospital length of stay was greater for that same group.

At a 13-month follow-up (4-32), there was a trend towards higher mortality among LF patients (36.6% vs. 25.3%; p = 0.069) mainly driven by non-cardiac death rates (26.4% vs. 15.7%; p = 0.03). In a multivariate analysis, the presence of LF and functional class IV heart failure were predictors of death at 2 years.

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The risk factors for mortality at 2 years linked to LF were <60 mL/m estimated glomerular filtration rate (eGFR) decrease and Child-Pugh class B or C. The association of these two factors resulted in an 83% mortality rate for that period.

Conclusion

These findings suggest that TAVR is a feasible treatment for severe stenosis in patients with early stages of liver disease or as a bridge for therapy prior to healing liver treatment. Patients with Child-Pugh class B or C (especially in combination with renal impairment) have a very low survival rate, so TAVR should be considered carefully in order to avoid fruitless treatment. These results may contribute to the improvement of decision-making and management in relation to patients with liver disease.

Editorial Comment

This analysis shows that TAVR is feasible and safe for this patient group, without any further peri-procedural complications, particularly related to bleeding.

While transesophageal Doppler echocardiography was less commonly used in this analysis, this minimally invasive strategy has been shown to be feasible and safe, thus avoiding related complications (particularly in patients with esophageal varicose veins).

The fact that cardiac mortality rates are similar among groups is encouraging. However, as expected for this group, non-cardiac death rates are higher, particularly among patients with Child-Pugh class B-C and renal function impairment.

Courtesy of Dr. Carlos Fava.

Original title: Clinical Outcomes and Prognosis Markers of Patients with Liver Disease Undergoing Trancatheter Aortic Valve Replacement:  A Propensity Score-Matched Analysis.

Reference: Gabriela Tirado-Conte et al. Circ Cardiovasc Interv 2018:e005727.DOI:10.1161.

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