Risk of mortality following transcatheter aortic valve replacement for low-flow low-gradient aortic stenosis

Wilde, Nihal; Sugiura, Akira; Sedaghat, Alexander; Becher, Marc Ulrich; Kelm, Malte; Baldus, Stephan; Nickenig, Georg; Veulemans, Verena; Tiyerili, Vedat

doi:10.1007/s00392-020-01752-4

Cited by 3 publications

(6 citation statements)

References 31 publications

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“…Mortality rates in both LFLG groups were higher after one, two, and three years, even after adjustment in comparison to HG, and mortality in classical LFLG was higher than in paradoxical LFLG. This result is in line with most published literature [ 8 , 17 ] but in contrast to a meta-analysis from 2019 where mortality rates in pLFLG and cLFLG patients seemed comparable [ 20 ] and a propensity-matched analysis with comparable 1-year mortality in pLFLG and HG patients [ 10 ]. Interestingly, in our study, the death cause differed significantly between groups, and HG patients tended to have lower rates of cardiovascular death.…”

Section: Discussionsupporting

confidence: 90%

“…In the subset of patients with paradoxical LFLG, the higher rate of prognostically relevant comorbidities such as CKD or AF determines mortality. In this regard, our analysis is similar to the literature [ 8 , 17 ]. Low-flow state has been described as an independent predictor of mortality in patients with preserved LVEF before [ 22 ].…”

Section: Discussionsupporting

confidence: 71%

“…This study is one of the largest published single-center analyses with an adequate follow-up time comparing outcomes of 447 patients with classical and 373 patients with paradoxical LFLG AS to patients with HG AS. It comprises an STS score-adjusted mortality analysis, a comparison of cardiovascular death rates, and one of the first to analyze LFLG patients according to the new VARC-3 endpoint definitions [ 17 ]. The fraction of cLFLG (25%) and pLFLG (21%) patients is substantially higher than in the published literature [ 5 , 18 ].…”

Section: Discussionmentioning

confidence: 99%

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TAVI in patients with low-flow low-gradient aortic stenosis–short-term and long-term outcomes

et al. 2022

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Objectives The study objective was to characterize different groups of low-flow low-gradient (LFLG) aortic stenosis (AS) and determine short-term outcomes and long-term mortality according to Valve Academic Research Consortium-3 (VARC-3) endpoint definitions. Background Characteristics and outcomes of patients with LFLG AS undergoing transcatheter aortic valve implantation (TAVI) are poorly understood. Methods All patients undergoing TAVI at our center between 2013 and 2019 were screened. Patients were divided into three groups according to mean pressure gradient (dPmean), ejection fraction (LVEF), and stroke volume index (SVi): high gradient (HG) AS (dPmean ≥ 40 mmHg), classical LFLG (cLFLG) AS (dPmean < 40 mmHg, LVEF < 50%), and paradoxical LFLG (pLFLG) AS (dPmean < 40 mmHg, LVEF ≥ 50%, SVi ≤ 35 ml/m2). Results We included 1776 patients (956 HG, 447 cLFLG, and 373 pLFLG patients). Most baseline characteristics differed significantly. Median Society of Thoracic Surgeons (STS) score was highest in cLFLG, followed by pLFLG and HG patients (5.0, 3.9 and 3.0, respectively, p < 0.01). Compared to HG patients, odds ratios for the short-term VARC-3 composite endpoints, technical failure (cLFLG, 0.76 [95% confidence interval, 0.40–1.36], pLFLG, 1.37 [0.79–2.31]) and device failure (cLFLG, 1.06 [0.74–1.49], pLFLG, 0.97 [0.66–1.41]) were similar, without relevant differences within LFLG patients. NYHA classes improved equally in all groups. Compared to HG, LFLG patients had a higher 3-year all-cause mortality (STS score-adjusted hazard ratios, cLFLG 2.16 [1.77–2.64], pLFLG 1.53 [1.22–193]), as well as cardiovascular mortality (cLFLG, 2.88 [2.15–3.84], pLFLG, 2.08 [1.50–2.87]). Conclusions While 3-year mortality remains high after TAVI in LFLG compared to HG patients, symptoms improve in all subsets after TAVI. Graphical abstract

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

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TAVI in patients with low-flow low-gradient aortic stenosis–short-term and long-term outcomes

et al. 2022

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“…We were not able to show a significant prediction of hospitalization for heart failure nor the combined endpoint of HHF and mortality at 1 year. In addition, multivariate analysis suggests an independent association of the GWTG-HF score with mortality after adjustment for clinically relevant variables such as LVEF, SVI, associated PPI, PVL, and mitral regurgitation [ 16 , 17 ]. In addition to an increased GWTG-HF score, reduced SVI and PPI also turned out to be possible predictors.…”

Section: Discussionmentioning

confidence: 99%

Prognostic Impact of the Get-with-the-Guidelines Heart-Failure Risk Score (GWTG-HF) after Transcatheter Aortic Valve Replacement in Patients with Low-Flow–Low-Gradient Aortic Valve Stenosis

et al. 2023

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Objectives: This study examined the prognostic value of the get-with-the-guidelines heart-failure risk score (GWTG-HF) on mortality in patients with low-flow–low-gradient aortic valve stenosis (LFLG-AS) after transcatheter aortic valve implantation (TAVI). Background: Data on feasibility of TAVI and mortality prediction in the LFLG-AS population are scarce. Clinical risk assessment in this particular population is difficult, and a score has not yet been established for this purpose. Methods: A total of 212 heart failure (HF) patients with real LFLG-AS were enrolled. Patients were classified into low-risk (n = 108), intermediate-risk (n = 90) and high-risk (n = 14) groups calculated by the GWTG-HF score. Clinical outcomes of cardiovascular events according to Valve Academic Research Consortium (VARC-2) recommendations and composite endpoint of death and hospitalization for heart failure (HHF) were assessed at discharge and 1 year of follow-up. Results: Baseline parameters of the groups showed a median age of 81.0 years [77.0; 84.0] (79.0 vs. 82.0 vs. 86.0, respectively p < 0.001), median EuroSCORE II of 6.6 [4.3; 10.7] (5.5 vs. 7.2 vs. 9.1, p = 0.004) and median indexed stroke volume of 26.7 mL/m2 [22.0; 31.0] (28.2 vs. 25.8 vs. 25.0, p = 0.004). The groups significantly differed at follow-up in terms of all-cause mortality (10.2 vs. 21.1 vs. 28.6%; p < 0.035). There was no difference in intrahospital event rate (VARC). Postprocedural mean gradients were lower in high-risk group (7.0 vs. 7.0 vs. 5.0 mmHg, p = 0.011). No differences in postprocedural aortic valve area (1.9 vs. 1.7 vs. 1.9 cm2, p = 0.518) or rate of device failure (5.6 vs. 6.8 vs. 7.7%, p = 0.731) could be observed. After adjustment for known predictors, the GWTG score (HR 1.07 [1.01–1.14], p = 0.030) as well as pacemaker implantation (HR 3.97 [1.34–11.75], p = 0.013) turned out to be possible predictors for mortality. An increase in stroke volume index (SVI) was, in contrast, protective (HR 0.90 [0.83–0.97]; p = 0.006). Conclusions: The GWTG score may predict mortality after TAVI in LFLG-AS HF patients. Interestingly, all groups showed similar intrahospital event and mortality rates, independent of calculated mortality risk. Low SVI and new conduction disturbances associated with PPI after THV implantation had negative impact on mid-term outcome in post-TAVI HF-patients.

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“…A cardiac dysfunction with low LVEF and low-flow low-gradient aortic stenosis is associated with an increased short-term and 1-year mortality in patients undergoing TAVR. 8 Therefore, patients with reduced cardiac output and impaired intraprocedural blood pressure show higher mortality rates compared with patients with preserved EF and stable hemodynamics. 9 Considering these recognitions, implanters must be aware of a higher risk of intraprocedural hemodynamic instability leading to severe adverse events such as CPR.…”

Section: Discussionmentioning

confidence: 99%

Outcomes and Characteristics of Patients with Intraprocedural Cardiopulmonary Resuscitation during TAVR

Gerfer

Kuhn

Gablac

et al. 2022

Thorac Cardiovasc Surg

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Background Transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement (AVR) for higher risk patients. Periprocedural TAVR complications decreased with a growing expertise of implanters. Yet, TAVR can be accompanied by life-threatening adverse events such as intraprocedural cardiopulmonary resuscitation (CPR). This study retrospectively analyzed predictors and outcomes in a cohort of patients from a high-volume center undergoing periprocedural CPR during TAVR. Methods A total of 729 patients undergoing TAVR, including 59 with intraprocedural CPR, were analyzed with respect to peri- and postprocedural outcomes. Results Patients undergoing CPR showed a significantly lower left ventricular ejection fraction (LVEF) and lower baseline transvalvular mean and peak pressure gradients. The systolic blood pressure measured directly preoperatively was significantly lower in the CPR cohort. CPR patients were in a higher need for intraprocedural defibrillation, heart–lung circulatory support, and conversion to open heart surgery. Further, they showed a higher incidence of atrioventricular block grade III , valve malpositioning, and pericardial tamponade. The in-hospital mortality was significantly higher after intraprocedural CPR, accompanied by a higher incidence of disabling stroke, new pacemaker implantation, more red blood cell transfusion, and longer stay in intensive care unit. Conclusion Impaired preoperative LVEF and instable hemodynamics before valve deployment are independent risk factors for CPR and are associated with compromised outcomes. Heart rhythm disturbances, malpositioning of the prosthesis, and pericardial tamponade are main causes of the high mortality of 17% reported in the CPR group. Nevertheless, mechanical circulatory support and conversion to open heart surgery reduce mortality rates of CPR patients.

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Risk of mortality following transcatheter aortic valve replacement for low-flow low-gradient aortic stenosis

Cited by 3 publications

References 31 publications

TAVI in patients with low-flow low-gradient aortic stenosis–short-term and long-term outcomes

TAVI in patients with low-flow low-gradient aortic stenosis–short-term and long-term outcomes

Prognostic Impact of the Get-with-the-Guidelines Heart-Failure Risk Score (GWTG-HF) after Transcatheter Aortic Valve Replacement in Patients with Low-Flow–Low-Gradient Aortic Valve Stenosis

Outcomes and Characteristics of Patients with Intraprocedural Cardiopulmonary Resuscitation during TAVR

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