Outcomes After Transfemoral TAVR With Myocardial Injury
What are the clinical and echocardiographic prognostic implications of myocardial injury after transcatheter aortic valve replacement (TAVR)?
Patients treated with TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) trial were divided into tertiles (T1, T2, T3) based on the difference between the values on post-procedure day 1 and the baseline values of two cardiac biomarkers: cardiac troponin I (∆ cTnI), and creatine kinase-myocardial band fraction (∆ CK-MB). Patients were stratified according to transfemoral (TF; n = 1,840) or transapical (TA; n = 1,173) access route.
At 30 days after TF-TAVR, patients in the highest tertile (T3) of cardiac biomarker elevation had a higher rate of all-cause mortality (∆ cTnI T3 5.4% vs. T1 0.5%, p = 0.006; ∆ CK-MB T3 5.7% vs. T1 0.9%, p = 0.006) and cardiovascular mortality (∆ cTnI T3 4.9% vs. T1 0.5%, p = 0.01; ∆ CK-MB T3 3.9% vs. T1 0.5%, p = 0.02). At 1 year, only patients in the highest CK-MB tertile had higher rates of all-cause (25.4% vs. 16.8%, p = 0.02) and cardiovascular (10.3% vs. 5.0%) mortality. Multivariable analysis demonstrated that greater release of cardiac biomarkers was independently associated with increased mortality in the TF population. After TA-TAVR, being in the highest tertile of cardiac biomarker elevation had no influence on clinical and echocardiographic outcomes at 30 days and 1 year.
After TF-TAVR, a greater degree of myocardial injury was associated with higher rates of 30-day all-cause and cardiovascular mortality. At 1 year, being in the highest tertile of ∆ CK-MB was correlated with a higher rate of all-cause and cardiac mortality. However, the level of myocardial injury after TA-TAVR had no demonstrable impact on clinical and echocardiographic outcomes.
Myocardial damage following cardiac surgery or percutaneous coronary intervention is associated with increased risk of cardiovascular morbidity and mortality. Myocardial injury after TAVR would be expected to be influenced by both patient- and procedure-specific factors. Data from this study suggest that greater increases in post-procedure cardiac biomarker values were associated with increased short-term all-cause mortality among patients who underwent transfemoral but not transapical TAVR. It seems likely that more subtle patient-specific changes in cardiac biomarkers are masked after transapical TAVR, due to the large increase in biomarkers associated with surgical manipulation of the apical left ventricular myocardium.
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