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Cardiac Damage and Quality of Life After Aortic Valve Replacement
Quick Takes
- Retrospective analysis from the PARTNER 2 and 3 trials evaluated the relationship between baseline cardiac damage (defined as stage 0: no extravalvular damage; stage 1: left ventricular damage; stage 2: left atrial/mitral valve damage; stage 3: pulmonary vasculature/tricuspid valve damage; and stage 4: right ventricular damage) prior to AVR and 1-year health status and outcomes after AVR.
- Extent of cardiac damage at baseline was associated with lower KCCQ scores both at baseline and at 1 year after AVR and with increased rates of a poor outcome (death, KCCQ decline) at 1 year.
- Each 1-stage increase in baseline cardiac damage was associated with a 24% increase in the odds of a poor outcome at 1 year.
Study Questions:
What is the association of cardiac damage on health status both before and after aortic valve replacement (AVR)?
Methods:
Patients from the PARTNER 2 and 3 trials were pooled and classified by echocardiographic cardiac damage stage at baseline and 1 year as previously described (stage 0: no extravalvular damage; stage 1: left ventricular damage; stage 2: left atrial/mitral valve damage; stage 3: pulmonary vasculature/tricuspid valve damage; and stage 4: right ventricular damage). They examined the association between baseline cardiac damage and 1-year health status (assessed by the Kansas City Cardiomyopathy Questionnaire Overall Score [KCCQ-OS]).
Results:
Among 1,974 patients (794 surgical AVR [SAVR], 1,180 transcatheter AVR [TAVR]), the extent of cardiac damage at baseline was associated with lower KCCQ scores both at baseline and at 1 year after AVR (p < 0.0001) and with increased rates of a poor outcome (death, KCCQ-OS <60, or a decline in KCCQ-OS of ≥10 points) at 1 year (stages 0-4: 10.6% vs. 19.6% vs. 29.0% vs. 44.7% vs. 39.8%; p < 0.0001). In a multivariable model, each 1-stage increase in baseline cardiac damage was associated with a 24% increase in the odds of a poor outcome (95% confidence interval [CI], 9-41%; p = 0.001). Change in stage of cardiac damage at 1 year after AVR was associated with the extent of improvement in KCCQ-OS over the same period (mean change in 1-year KCCQ-OS: improvement ≥1 stage +26.8 [95% CI, 24.2-29.4] vs. no change +21.4 [95% CI, 20.0-22.7] vs. deterioration ≥1 stage +17.5 [95% CI, 15.4-19.5]; p < 0.0001).
Conclusions:
The extent of cardiac damage prior to AVR has important impact on health status outcomes, both cross-sectionally and after AVR.
Perspective:
Retrospective analysis from the PARTNER 2 and 3 trials evaluated the relationship between baseline cardiac damage (defined as stage 0: no extravalvular damage; stage 1: left ventricular damage; stage 2: left atrial/mitral valve damage; stage 3: pulmonary vasculature/tricuspid valve damage; and stage 4: right ventricular damage) prior to AVR and 1-year health status and outcomes after AVR. Findings show that extent of extravalvular cardiac damage before AVR was associated with poor health status at the time of AVR and was associated with increased rates of poor outcomes (health status and death) at 1 year. The authors suggest revisiting the treatment threshold for aortic valve stenosis and their findings lend support to the hypothesis that earlier detection and treatment of aortic stenosis may better optimize survival and health status after AVR. Ongoing randomized controlled trials will provide important insight into more detailed parameters for considering therapy.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Echocardiography, Heart Valve Diseases, Mitral Valve Insufficiency, Quality of Life, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency
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