Patients suffering from immune-mediated chronic inflammatory disease (CID) face a high risk of developing heart disease, including aortic valve disease. Inflammatory vascular disease when triggered by an autoimmune condition, can prompt a harmful response leading to valve degeneration, with increased calcification and fibrosis, and the associated progression of stenosis, failure or both.
Prior research has shown a prevalence of up to 33% of aortic disease in patients with rheumatoid arthritis. The presence of generalized CID largely tilts the scales in favor of a transcatheter aortic valve replacement (TAVR), given the high surgical risk in these patients and the concomitant use of immunosuppressors, which would complicate post procedural management.
However, information on long term prognosis of TAVR in this group of patients is limited, mainly based on a series of cases. Therefore, the aim of this study was to assess long term outcomes (5 years) in patients with CID vs. no CID patients, undergoing TAVR.
The study included consecutive patients from the Lucerne Heart Center in Switzerland, participants in the SwissTAVI. The population was divided into two groups: those with CID and those without CID. Autoimmune patients included those with rheumatoid arthritis, vasculitis (giant cell, Takayasu, granulomatosis, microscopic polyangiitis), connective tissue diseases (systemic sclerosis, SLE, Sjögren’s, dermatomyositis, PM), sarcoidosis, rheumatic polymyalgia, psoriasis (arthritis), ankylosing spondylitis and inflammatory bowel diseases such as Crohn’s and ulcerative colitis.
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A clinical and echocardiographic followup was carried out at 5 years; the primary outcome was defined as all-cause mortality and valve dysfunction (structural degeneration, thrombosis and endocarditis). Secondary outcomes were also assessed, such as rehospitalization for bleeding, cardiac failure, endocarditis and PCI or stroke.
Outcomes were obtained from 1000 consecutive patients undergoing TAVR, 107 diagnosed with CID. The most common conditions were polymyalgia (31%), rheumatoid arthritis (28%), psoriasis (18%), followed by vasculitis (7%) and collagenopathies (5%). Mean age was 81±6 years and the DIC group was comprised mainly of women (60%), vs 44% of women in the other group. There was higher prevalence of comorbidities among CID patients, such as lung conditions (22% vs. 13%, P=0.046), atrial fibrillation (32% vs. 20%) and higher use of drug therapy (40% with corticoids and 7% with biological treatments).
When looking at long term events, the study revealed higher incidence of infections (pneumonia and urinary infection). During followup, 372 of 1000 patients died, and 54 of 1000 presented valve dysfunction. Risk models did not show a significant link between CID and mortality or the development of valve dysfunction. Also, survival curves did not vary with the presence of valve dysfunction between patients with and without CID.
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We should highlight the increased risk of rehospitalization in patients with CID, mainly for bleeding (HR, 2.07 [CI, 1.20–3.58]; P=0.009) and infection (HR, 1.69 [CI, 1.15–2.48]; P=0.007). Multivariable analysis confirmed CID as main predictor of rehospitalization for bleeding (HR, 1.93 [CI, 1.09–3.42]; P=0.024) and infections (HR, 1.62 [CI, 1.08–2.42]; P=0.018), excluding infectious endocarditis.
Conclusions
This study based on SwissTAVI data has revealed long term outcomes favor the use of TAVR in patients with chronic inflammatory disease, with no significant differences in mortality or valve degeneration vs. patients without CID. However, there was an increased risk of bleeding and infection. Finally, the limitations of single-center study data should not be overlooked.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Patients With Chronic Inflammatory Disease.
Reference: Brunner S, Covtun O, Moccetti F, Loretz L, Bossard M, Attinger-Toller A, Cuculi F, Wolfrum M, Kurmann R, Toggweiler S. Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Patients With Chronic Inflammatory Disease. J Am Heart Assoc. 2024 Feb 23:e032250. doi: 10.1161/JAHA.123.032250. Epub ahead of print. PMID: 38390801.
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