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Regression of LV Mass After TAVR in PARTNER Trials and Registries
Quick Takes
- Every 10% decrease in LV mass index at 1 year following TAVR is associated with a 5% reduction in all-cause mortality, during ~2-5 years of follow-up.
- Patients with residual severe LV hypertrophy (LVH) at 1 year post-TAVR are at >70% risk of mortality and rehospitalization compared with patients with no residual LVH.
Study Questions:
What is the relationship between left ventricular mass index (LVMi) following transcatheter aortic valve replacement (TAVR) and long-term clinical outcomes?
Methods:
Subjects had severe symptomatic aortic stenosis (AS); underwent TAVR with a self-expanding prosthesis in the PARTNER 1A, 2A, and S3 trials and registries; had moderate or severe LV hypertrophy (LVH) on echocardiogram pre-TAVR (defined as LVMi ≥109 g/m2 for women and ≥132 g/m2 for men); and had LVMi measured on echocardiogram 1 year post-TAVR. Echocardiograms were analyzed in core laboratories. Clinical events included all-cause death, cardiovascular (CV) death, repeat hospitalization, stroke, major vascular complications, life-threatening or major bleeding, and acute kidney injury. Adjudicated outcomes between 1 and 5 years post-TAVR that were available at the time of analysis were considered (PARTNER 1A, 5 years; PARTNER 2A, 2 years; PARTNER S3, 3 years). Patients were grouped into quartiles based on degree of LVH regression. The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to assess quality of life.
Results:
A total of 1,434 patients were included in the analysis (434 with moderate LVH, 1,000 with severe LVH). Mean age was 84 ± 7 years, and 53% were women. In a multivariable model, baseline LVMi and baseline relative wall thickness were positively associated with LVMi regression, whereas moderate/severe aortic regurgitation (AR) at discharge or 30-days post-TAVR was negatively associated with LVMi regression. Systolic blood pressure at 1 year post-TAVR, sex, and diabetes mellitus were not significantly associated with LVH regression in the multivariable model.
With regard to clinical outcomes, median duration of follow-up was 3.70 years (interquartile range, 2.60-4.81 years). After adjustment for several variables including baseline LVMi, Society of Thoracic Surgeons score, and AR severity at 30 days, every 10% decrease in LVMi was linearly associated with a 5% reduction in all-cause mortality (adjusted hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.91-0.98; p = 0.004) and in CV mortality or rehospitalization (HR, 0.95; 95% C,I 0.91-0.99; p = 0.009). Residual severe LVH at 1 year post-TAVR was present in 39% of patients (36% of men, 42% of women). As compared with no LVH, residual severe LVH was associated with increased all-cause mortality (HR, 1.71; 95% CI, 1.20-2.44; p = 0.003) and CV mortality or hospitalization (HR, 1.70; 95% CI, 1.17-2.48; p = 0.006). Residual moderate LVH was not significantly associated with clinical endpoints (HR for all-cause mortality, 1.10; 95% CI, 0.73-1.66; p = 0.64; HR for CV mortality or rehospitalization, 1.11; 95% CI, 0.72-1.72; p = 0.63). Compared with patients in the lowest quartile of LVMi regression, those in the highest two quartiles had better quality of life at 2 years post-TAVR, as evidenced by KCCQ scores >5 points higher.
Conclusions:
Regression of LVH following TAVR is associated with a lower risk of all-cause mortality, CV mortality, and rehospitalization. Residual severe LVH, in particular, is strongly associated with poor long-term clinical outcomes.
Perspective:
This study emphasizes the point that favorable reverse remodeling of the left ventricle after TAVR is far from universal. Efforts to identify AS patients who can benefit from earlier TAVR before development of symptoms or decline in LV systolic function, based on biomarkers and myocardial tissue characterization with cardiovascular magnetic resonance, include the EVoLVeD trial (NCT03094143). A notable limitation of the PARTNER studies is lack of data on cardiac amyloidosis, which is relatively common among elderly patients with AS, and carries a poor prognosis.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Acute Kidney Injury, Aortic Valve Insufficiency, Aortic Valve Stenosis, Blood Pressure, Cardiac Surgical Procedures, Echocardiography, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hypertrophy, Left Ventricular, Patient Discharge, Quality of Life, Stroke, Transcatheter Aortic Valve Replacement
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