Valve Hemodynamic Deterioration After TAVR
What are the incidence, timing, and predictors of valve deterioration after transcatheter aortic valve replacement (TAVR)?
This multicenter registry followed 1,521 patients treated with TAVR and with serial follow-up echocardiograms, and examined characteristics of valve hemodynamic deterioration (VHD), defined as a ≥10 mm Hg increase in mean gradient as compared to the discharge study.
A total of 68 individuals (4.5%) had VHD during the mean follow-up of 20 ± 13 months. The mean annualized change in mean gradient was 0.30 ± 5.0 mm Hg per year. Among patients with VHD, the mean gradient increased from 9.5 ± 5.0 mm Hg at discharge to 26.1 ± 11.0 mm Hg at follow-up (p < 0.001). Independent predictors of VHD included the absence of anticoagulation at discharge (p = 0.002), valve-in-valve procedure (p = 0.03), a 23 mm valve size (p = 0.02), and greater body mass index (p = 0.001). Among the 60 patients with VHD not on anticoagulation at the time of diagnosis, six were treated with warfarin, and four of these six had normalization of gradients and resolution of VHD during follow-up, with one demonstrating no change, and one lost to follow-up.
VHD was observed in nearly 5% of individuals following TAVR during the follow-up period. Independent predictors of VHD include the absence of anticoagulation at discharge, a valve-in-valve procedure, a small valve size, and a large body mass index.
VHD following TAVR was observed in nearly 5% of individuals in this multicenter registry. While the cause of the increased gradients cannot be determined from this study, valve thrombosis is a potential cause. It is intriguing that among those with VHD and not on anticoagulation, four of six in which anticoagulation was started demonstrated resolution of the elevated gradients, suggesting that valve thrombosis may be playing a role and that this may be treatable. A future prospective study is needed to determine the role of advanced imaging in the evaluation of patients with increased gradients, and to compare treatment strategies in patients with suspected VHD.
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