Valvular heart disease
Long-Term Outcome of Patients With Moderate and Severe Prosthetic Aortic Valve Regurgitation After Transcatheter Aortic Valve Implantation

https://doi.org/10.1016/j.amjcard.2012.07.010Get rights and content

Recently, moderate and severe postprocedure aortic regurgitations (ARs) have been identified as independent risk factors for short- and midterm mortality after transcatheter aortic valve implantation (TAVI). However, very few data exist on the long-term outcome of postprocedure AR. From 2008 to 2011, 198 consecutive patients with severe aortic stenosis successfully underwent TAVI with the CoreValve prosthesis (Medtronic CV, Minneapolis, Minnesota). After the procedure, patients were subdivided into groups depending on the presence of moderate/severe AR. The primary study end point was death from any cause after TAVI. The secondary end point was defined as cardiovascular death. In study patients (80 ± 6 years old, logistic European System for Cardiac Operative Risk Evaluation 22 ± 16%, left ventricular ejection fraction 53 ± 13%), moderate/severe AR occurred in 28 patients (14%). Despite similar baseline characteristics, patients with moderate/severe AR had higher 30-day and 1-year mortality rates than patients with none/mild AR (21% vs 6%, p = 0.019; 57% vs 16%, p <0.001, respectively). During a mean follow-up of 535 ± 333 days, the primary end point was reached in 54 and the secondary end point in 33 patients. Moderate/severe AR was the strongest independent risk factor of all-cause-mortality (hazard ratio 4.89, 95% confidence interval 2.78 to 8.56, p <0.001) and the strongest independent risk factor of cardiovascular mortality (hazard ratio 7.90, 95% confidence interval 3.95 to 15.81, p <0.001). In conclusion, moderate and severe postprocedure ARs are not uncommon complications after TAVI. Although long-term outcome of patients with none/mild AR is favorable, outcome of patients with moderate/severe AR is dismal.

Section snippets

Methods

Patients with symptomatic, severe aortic stenosis (aortic valve area ≤1.0 cm2) and high risk for surgical aortic valve replacement were screened for transfemoral or transaxillary TAVI. Risk of surgical aortic valve replacement was estimated with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE). Indications, contraindications, and anatomic requirements for TAVI were described previously.16

After the procedure patients were subdivided into groups depending on the

Results

In total 202 consecutive patients with native aortic stenosis (n = 197) or degenerated aortic bioprosthesis (n = 5) who underwent transfemoral (n = 197) or transaxillary (n = 5) TAVI with the CoreValve prosthesis were enrolled.

During the procedure 3 patients died (rupture of eccentric calcified aortic base, n = 1; fatal vascular access-related complications, n = 2). These patients died before the prosthesis was implanted and evaluation of AR was not possible. Hence, these patients were excluded

Discussion

Our study highlights the prognostic impact of moderate and severe ARs after TAVI with a self-expandable transcatheter valve. The main finding is that moderate/severe AR is a main contributor to long-term all-cause and cardiovascular mortality. In addition, we illustrate the mechanisms of AR and meaning of AR on functional status and hemodynamic function.

Although transcatheter valves have favorable hemodynamic performance, prosthetic AR is a common complication.22 Recently, we described several

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