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Late Cardiac Death in Patients Undergoing Transcatheter Aortic Valve Replacement: Incidence and Predictors of Advanced Heart Failure and Sudden Cardiac Death | Journal Scan
Study Questions:
What are the incidence, timing, and predictors of cardiac death from advanced heart failure (HF) and sudden cardiac death (SCD) in patients undergoing transcatheter aortic valve replacement (TAVR)?
Methods:
This study included 3,726 patients who underwent TAVR using balloon (57%) or self-expandable (43%) valves. Causes of death were defined according to the Valve Academic Research Consortium-2. Survival rates were summarized using Kaplan-Meier estimates, and log-rank tests were used to perform comparisons between groups. Predictors of death from HF and SCD were analyzed using univariate and multivariate proportional hazard models (cumulative outcomes).
Results:
At a mean follow-up of 22 ± 18 months, 155 patients had died due to advanced HF (15.2% of total deaths, 46.1% of deaths from cardiac causes) and 57 had died due to SCD (5.6% of deaths, 16.9% of cardiac deaths). Baseline comorbidities (chronic obstructive pulmonary disease, atrial fibrillation, left ventricular ejection fraction ≤40%, lower mean transaortic gradient, pulmonary artery systolic pressure >60 mm Hg; p < 0.05 for all) and two procedural factors (transapical approach, hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.60-3.54; p < 0.001; presence of moderate or severe aortic regurgitation after TAVR, HR, 2.79; 95% CI, 1.82-4.27; p < 0.001) independently predicted death from advanced HF. Left ventricular ejection fraction ≤40% (HR, 1.93; 95% CI, 1.05-3.55; p = 0.033) and new-onset persistent left bundle-branch block following TAVR (HR, 2.26; 95% CI, 1.23-4.14; p = 0.009) were independently associated with an increased risk of SCD. Patients with new-onset persistent left bundle-branch block and a QRS duration >160 ms had a greater SCD risk (HR, 4.78; 95% CI, 1.56-14.63; p = 0.006).
Conclusions:
The authors concluded that advanced HF and SCD accounted for two-thirds of cardiac deaths in patients after TAVR.
Perspective:
This study reports that advanced HF and SCD accounted for approximately two-thirds of cardiac deaths following TAVR, which occurred most frequently during the first 6 months after the procedure. Predictors of cardiac death after TAVR included potentially modifiable factors, such as a transapical approach and at least residual aortic regurgitation, both associated with death from HF, and development of new-onset persistent left bundle-branch block, associated with SCD, particularly in those with QRS duration >160 ms. These results should allow identification of patients at the highest risk of dying of HF or SCD within the first months following TAVR, and contribute to improved clinical decision making.
Keywords: Transcatheter Aortic Valve Replacement, Heart Failure, Death, Sudden, Cardiac, Arteries, Incidence, Survival Rate, Lipids, Kaplan-Meier Estimate, Proportional Hazards Models
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