TAVR Viable Option For Patients With Cardiogenic Shock, Despite Increased Mortality
TAVR may be a viable option for patients with aortic stenosis (AS) presenting with acute cardiogenic shock, according to a study published June 1 in JACC: Cardiovascular Interventions.
Luke Masha, MD, MPH, FACC, et al., linked data from the STS/ACC TVT Registry with claims data from the Centers for Medicare and Medicaid Services (CMS) to identify Medicare fee-for-service patients with AS who presented with cardiogenic shock before TAVR. The researchers compared this group to a cohort of high-risk patients who did not have cardiogenic shock before undergoing TAVR. The study's primary outcome was 30-day mortality following TAVR. Secondary outcomes included 30-day complications after TAVR.
The median STS score in the cardiogenic shock group was 9.8 vs. 10.3 in the high-risk control cohort. The shock population compared with the high-risk population was slightly younger (median age 83 vs. 86 years) and predominantly male (55.5% vs. 45.3% male). They were also more likely to have had a myocardial infarction (30.6% vs. 27.6%), at least moderate aortic insufficiency preprocedure (21.9% vs. 19.2%), and at least moderate mitral regurgitation (38.6 vs. 35.0%). Nonfemoral access for TAVR was more common for the shock population (21.8% vs. 16.2%) and they were less likely to undergo annulus sizing with CT angiography (60.1% vs. 64.1%).
A total of 2,220 patients with AS and cardiogenic shock, representing 4.1% of the U.S. TAVR population, were compared with 12,851 high-risk patients undergoing TAVR. Patients with cardiogenic shock had higher 30-day mortality vs. those without cardiogenic shock (19.1% vs. 4.9%). Compared with the control population, 30-day mortality in the cardiogenic shock group was associated with an adjusted hazard ratio of 3.7 (95% confidence interval [CI], 3.1-4.5; p<0.001). In addition, 30-day mortality was higher among patients with prior cardiac arrest or who required preprocedural mechanical circulatory support.
The 30-day rate of complications also was higher in the cardiogenic shock group. A lack of major complications at 30 days was not associated with a reduction in 30-day mortality. Among all patients who were alive 30 days post TAVR, the cardiogenic shock group had a higher mortality risk through one year, compared with the control group.
According to the researchers, TAVR is a viable treatment option for AS patients presenting with cardiogenic shock. Although these patients may have a higher mortality risk up to one year after the procedure, mortality "does not appear to be particularly driven by procedural complications, but rather by the degree of shock itself," they conclude.
Keywords: Shock, Cardiogenic, Mitral Valve Insufficiency, Transcatheter Aortic Valve Replacement, Aortic Valve Stenosis, Aortic Valve Insufficiency, Myocardial Infarction, Registries, National Cardiovascular Data Registries, STS/ACC TVT Registry
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