Predictors and Impact of Myocardial Injury After TAVR
What is the clinical importance of elevated cardiac biomarkers following transcatheter aortic valve replacement (TAVR)?
This multicenter study examined 1,131 patients treated with TAVR, and compared outcomes to creatine kinase-myocardial band (CK-MB) levels obtained at baseline and at 6, 12, 24, 48, and 72 hours post-TAVR. Patient outcomes included overall and cardiovascular mortality, and echocardiography changes at 6 and 12 months of follow-up. An elevated CK-MB was defined as any value above the 99th percentile of a normal population.
Elevated CK-MB values were observed in 8.0% of patients at baseline and 65.6% of patients following TAVR. The median increase was 1.6-fold (interquartile range, 0.9- to 2.8-fold) at 12-24 hours after the procedure. An elevated CK-MB was noted in 97.3% of the transapical cohort (median peak increase, 2.2-fold) versus 54.4% of the non-transapical cohort (median peak increase, 1.2-fold; p < 0.001). Procedural variables associated with greater increase in CK-MB included balloon-expandable versus self-expandable prosthesis (p = 0.02), transapical approach (p < 0.001), early TAVR experience (p < 0.001), and complications (lack of device success, major bleeding, major vascular complications, need for second valve/embolization, conversion to surgery, and coronary obstruction; p < 0.05 for each). Patients with stable or reduced ejection fraction on follow-up echocardiography had higher post-TAVR CK-MB levels compared to those with improved ejection fraction (p = 0.004). After multivariable adjustment, CK-MB elevation was associated with increased 30-day mortality (hazard ratio [HR], 1.7; 95% confidence interval [CI], 1.3-2.4; p < 0.001), cumulative mortality (HR, 1.3; 95% CI, 1.1-1.5; p < 0.001), and cumulative cardiac mortality (HR, 1.4; 95% CI, 1.1-1.7; p = 0.003).
Elevated CK-MB is observed in approximately one third of patients treated with TAVR. A greater increase in CK-MB is associated with higher mortality.
Elevated biomarkers are observed in the majority of patients following TAVR, and unsurprisingly, this is most commonly observed in sites with less experience, when using an apical approach, or in cases with procedural complications. Generally, these complications would be known, and it is not clear how often an elevated CK-MB would be observed when it would be unexpected (e.g., TAVR using a transfemoral approach and without known complications). Patients with major TAVR complications are known to have increased rates of mortality, and it is not surprising that patients with an elevated CK-MB would also experience greater mortality. These findings do not support routine surveillance biomarkers following TAVR, but when observed, it should prompt examination for the underlying cause and perhaps closer follow-up.
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