For interventional cardiologists, treating an ST-segment elevation infarction in a patient with transcatheter aortic valve replacement (TAVR) is challenging in many ways. Longer door-to-balloon times and higher rates of primary angioplasty failure than in the general population are translated into very high short- and mid-term mortality.
This multicenter study, recently published in JACC, included 118 patients admitted with ST-segment elevation infarction at a mean of 225 days (range: 9 to 680 days) after valvular implantation.
The characteristics of post-TAVR infarction patients who underwent primary angioplasty were compared with 439 patients without prior TAVR who underwent primary angioplasty in the same time period.
The mean door-to-balloon time was higher for TAVR patients (40 minutes vs. 30 minutes [p = 0.003]). Procedure time, fluoroscopy time, radiation dose, and contrast volume were significantly higher for the TAVR population (p < 0.01 for all).
The primary angioplasty failure rate was 4x higher in those with implanted valves (16.5% vs. 3.9%; p < 0.001), including 5 patients whose culprit artery could not be catheterized.
In-hospital mortality was 25.4%, while mid-term mortality (7 months) was as high as 42.4%.
Renal impairment and Killip class >II were 3x more frequent in patients with previous TAVR (hazard ratio [HR]: 3.02; p = 0.004; and HR: 2.74; p = 0.004, respectively).
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All these more frequent events in the TAVR population explain the higher short- and mid-term mortality.
Conclusion
ST-segment elevation infarctions in patients with prior TAVR are associated with much higher short- and mid-term mortality. Longer door-to-balloon times and higher primary angioplasty failure rates are due, partly, to difficulties accessing coronary arteries.
Original Title: ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement.
Reference: Laurent Faroux et al. J Am Coll Cardiol. 2021 May 4;77(17):2187-2199. doi: 10.1016/j.jacc.2021.03.014.
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