Impact of bioprosthetic valve type on peri-procedural myocardial injury and mortality after transcatheter aortic valve replacement

Abstract

Peri-procedural myocardial injury (PPMI) is a common complication after transcatheter valve replacement (TAVR), often remaining clinically silent. The role of valve type on PPMI and the association between PPMI and mortality are still unclear. We sought to evaluate predictors and outcome of PPMI after TAVR, and the impact of self-expandable valve (SEV) vs. balloon-expandable valve (BEV) deployment on PPMI. Consecutive patients who underwent successful TAVR in a single-center from January 2014 to December 2019 were included. PPMI was defined according to a modified Valve Academic Research Consortium (VARC)-2 definition as a post-procedure elevation of troponin (with a peak value ≥ 15-times the upper-reference limit) < 72 h after TAVR. We included 596 patients, of whom 258 (43.3%) were men. Mean age was 83.4 ± 5.5 years. We deployed 368 (61.7%) BEV and 228 (38.3%) SEV. PPMI was observed in 471 (79.0%) patients. At multivariable analysis, SEV (OR 2.70, 95% CI 1.64–4.55, p < 0.001), creatinine clearance (OR 0.98, 95% CI 0.97–1.00, p = 0.011), and baseline ejection fraction (OR 1.05, 95% CI 1.02–1.07, p < 0.001) were independent predictors of PPMI; these findings were also confirmed using a propensity-weighted analysis. Thirty-day and 1-year all-cause mortality rates were 2.5% and 8.1%, respectively. No associations between PPMI and 30-day (p = 0.488) or 1-year (p = 0.139) all-cause mortality were found. Independent predictors of 30-day mortality were increasing EUROSCORE II (HR 1.16 per score point, 95% CI 1.08–1.19, p < 0.001) and life-threatening/major bleeding complications (HR 5.87, 95% CI 1.28–26.58, p = 0.019), whereas EUROSCORE II (HR 1.08, 95% CI 1.04–1.13, p = 0.031) and acute kidney injury (HR 2.59, 95% CI 1.20–5.35, p = 0.020) were related to 1-year mortality. PPMI is frequent after TAVR, but it does not affect 30-day or 1-year all-cause mortality. SEV implantation is associated with an increased frequency of PPMI.

Predictors of Permanent Pacemaker Implantation in Patients After Transcatheter Aortic Valve Replacement in a Chinese Population

“…Previous studies have reported that renal dysfunction at baseline predicted a higher increase of myocardial injury after the procedure. Additionally, myocardial injury after TAVR could lead to conduction disturbances, which may contribute to the need for PPM implantation ( 14 – 16 ). Thus, lower average CrCl may lead to worse kidney function at baseline, which plays an important role in patients requiring PPM implantation after TAVR.…”

Antithrombotic Therapy in Patients Undergoing Transcatheter Aortic Valve Implantation

“…The endothelialization process varies in time and completeness depending on the device size and type [13] and while theoretically, this may represent a concern for device thrombosis, currently there is no clear evidence that antithrombotic therapy has a true clinical impact [14]. On the other hand, it is well established that after TAVI patients are exposed to a higher and temporally variable risk of ischemic events, including transient ischemic attack (TIA), stroke, myocardial infarction (MI) [15][16][17][18][19][20][21][22][23][24] and valve thrombosis [25,26]. Hence, evaluating the impact of different antithrombotic strategies to mitigate this risk has been the core focus of multiple clinical studies.…”

Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement

“…Despite the relative low rate of VARC-2 defined MI after TAVR, a large majority of patients have a significant isolated elevation in cardiac biomarkers within 72 h after the procedure, matching post-procedural myocardial injury (PPMI) definition. Indeed, PPMI ranges from 20 to 79% in observational reports [60][61][62][63], but its impact on clinical outcome remains controversial. Some cohorts showed no association of PPMI with 30-day and long-term mortality [62][63][64], while others reported a significant relationship between PPMI and mortality rates [60,61,64].…”

“…Indeed, PPMI ranges from 20 to 79% in observational reports [60][61][62][63], but its impact on clinical outcome remains controversial. Some cohorts showed no association of PPMI with 30-day and long-term mortality [62][63][64], while others reported a significant relationship between PPMI and mortality rates [60,61,64]. Likewise, two meta-analyses gathering a large number of patients showed a significant association of PPMI after TAVR with both 30-day and long-term all-cause mortality [65,66].…”