Cardiac failure (CF) and sudden cardiac death (SCD) stand out as two of the main causes of death in patients with aortic stenosis. Although transcatheter aortic valve intervention has shown higher survival, these two continue to be the main conditions leading to patient death at followup.
In its early days, TAVR also showed benefits, but both SCD and CF continue to be the main causes of death.
We should note that transcatheter aortic valve replacement (TAVR) has evolved, especially in lower risk populations, alongside better, more modern devices, and increased operator and health team experience. Also, there are new strategies to reduce the need for definite pacemaker implantation after TAVR.
Nevertheless, at present, we still lack crucial information about the causes of death associated to these devices.
To answer this question, 5,421 TAVR patients treated with Evolut R/Pro/Pro+ from Medtronic or self-expandable SAPIEN S3/ULTRA from Edwards Lifesciences were analyzed.
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The population was mean age 80, and 44% were women. Also, 83% presented hypertension, 33% diabetes, 23% chronic obstructive pulmonary disease (EPOC), 61% kidney function deterioration, 40% prior coronary artery disease, 8.3% prior SAVR, 35% atrial fibrillation, 12% prior pacemaker, 1% automatic implantable cardiac defibrillator (AICD), 10.5% left bundle branch (LBBB) and 8% right bundle branch block (RBBB). Mortality STS score was 5.8%, with 55% mean ejection fraction.
90% were treated with a transfemoral approach, 75.7% received a self-expandable valve, and 6.3% were “valve-in-valve” cases. There was mild or severe regurgitation was observed in 5.4% of patients.
At 30 days, mortality rate was 2.4 %, 2.3% of patients saw stroke, 0.9% acute myocardial infarction (MI), 4.6% major or life threatening bleeding, 14.4% new left bundle branch block and 17% received a pacemaker.
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At 2 year followup, total mortality rate was 18%, and 50% of patients died because of heart conditions. CF represented 11.6% of deaths, while SD was responsible for 7.5%.
Mortality predictors of CF included atrial fibrillation, transthoracic approach, new LBBB, prior pacemaker implantation and low ejection fraction.
On the other hand, SCD predictors included estimated glomerular filtration rate (eGFR) lower than 60 ml/min, valve-in-valve, access other than femoral, and periprocedural ventricular arrhythmia.
Conclusion
To sum up, advanced cardiac failure and sudden death represent one in five deaths after TAVR in the contemporary practice. These potentially treatable factors, such as arrhythmia and dyssynchrony for cardiac failure, as well as valve-in-valve and periprocedural ventricular arrhythmia for sudden death, have been identified as significant contributors to these concerning stats.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Cardiac Death After Transcatheter Aortic Valve Replacement With Contemporary Devices.
Reference: Jules Mesnier, et at. J Am Coll Cardiol Intv 2023;16:2277–2290.
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