Study Explores Incidence and Predictors of Late Cardiac Death in TAVR Patients

Two-thirds of cardiac deaths following a transcatheter aortic valve replacement (TAVR) were the result of advanced heart failure (HF) and sudden cardiac death (SCD), according to a study published Feb. 2 in the Journal of the American College of Cardiology.

Led by Marina Urena, MD, the study examined 3,726 patients who underwent TAVR, performed through the transfemoral route (80 percent) or the transapical route (16 percent), using either balloon- (57 percent) or self-expandable (43 percent) valves. The mean age of patients was 81 years old, with fluctuation of eight years on either side. Twelve-lead electrocardiography tracings were recorded at baseline, immediately following the TAVR and at hospital discharge.

Results showed that advanced HF and SCD were the most common causes of death following a TAVR procedure. Further, the researchers found that baseline characteristics, such as chronic obstructive pulmonary disease, pre-existing paroxysmal or chronic atrial fibrillation, and the presence of moderate to severe aortic regurgitation after the TAVR, were associated with increased risk of death from advanced HF. At follow-up, 1,022 patients had died, 663 of which were from cardiovascular causes. The researchers further reported that "the present study showed … that an approximately two-fold increased risk of death from HF was associated with transapical access."

The authors conclude that their results "allow identification of the patients at the highest risk of dying of HF or SCD within the first months following TAVR and should contribute to improved clinical decision making."

In an accompanying editorial comment, Thierry Lefevre, MD, stated that "beyond technical achievements, the paper by Urena et al. sheds useful light on the risk of mortality from cardiac failure after TAVR, which, although substantial, is not ineluctable. Indeed, we can control three key factors: 1) selection of the transfemoral route whenever feasible and safe; 2) prevention of the occurrence of paravalvular leak >1 grade by optimal valve sizing and positioning and its correction by adequate post-dilation, a problem that newer-generation valves will probably solve; and 3) consideration of systematic pacemaker implantation or even resynchronization, in the presence of an left bundle branch block with large QRS width (>160 ms) for patients with significantly impaired left ventricular function."

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