Some risks for cardiac death post-TAVR may be avoided

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 - Electrocardiogram

In an international, real-world setting, two-thirds of late transcatheter aortic valve replacement (TAVR) cardiac deaths could be traced back to advanced heart failure and sudden cardiac death. Researchers found, however, some factors that led to increased risks in these patients were modifiable.

The analysis on data provided by 18 clinics in North and South America and Europe encompassed 3,726 patients who underwent TAVR. Marina Urena, MD, of the Quebec Heart & Lung Institute at Laval University in Quebec City, and colleagues reviewed patient outcomes through two years with the intent of determining predictors for cardiac death. For supplemental analysis, they found three groups within the patient population to determine further effects on outcomes: patients with new-onset persistent left bundle branch block (NOP-LBBB) without a pacemaker, NOP-LBBB with a pacemaker during hospitalization and patients with no NOP-LBBB.

Among all patients at a mean follow-up of 22 months, 15.2 percent had died of advanced heart failure and 5.6 percent had died of sudden cardiac death. Sudden cardiac death and advanced heart failure were responsible for 46.1 percent and 16.9 percent of cardiac deaths, respectively.

Urena et al noted that independent predictors for death due to advanced heart failure included two procedural factors: transapical approach (hazard ratio 2.38) and moderate to severe aortic regurgitation after TAVR (2.79). Baseline comorbidities, especially pre-existing paroxysmal or chronic atrial fibrillation (2.33) and pulmonary artery systolic pressure of more than 60 mm Hg (1.99) also had increased risk of death due to advanced heart failure. They did note that presence of moderate or severe aortic regurgitation before TAVR (0.24) had a protective effect against death from advanced heart failure.

Predictors of increased risk of sudden cardiac death included left ventricular ejection fraction of 40 percent or less before TAVR (1.93) and NOP-LBBB following TAVR (2.26). Patients with both had an increased risk of death of 12.3 percent at one year. NOP-LBBB and a QRS duration of more than 160 ms at discharge were also associated with increased risk (4.78). By one year, the rate of sudden cardiac death among patients with a QRS duration greater than 160 ms was 9.9 percent. Urena et al noted that implantation of a pacemaker or cardiac defibrillator reduced these risks significantly in patients with NOP-LBBB (0.71).

They suggested that in the future, physicians should assess strategies to reduce risks where possible, including seeking alternatives to a transapical approach if transfemoral is not viable, treatment of residual severe or moderate aortic regurgitation, the use of pacemakers in patients with NOP-LBBB when QRS duration was more than 160 ms or implantable cardiac defibrillation devices in patients with left ventricular dysfunction.

“In the meantime, our results allow identification of the patients at the highest risk of dying of HF [heart failure] or SCD [sudden cardiac death] within the first months following TAVR and should contribute to improved clinical decision-making,” Urena et al wrote.

The study was published in the Feb. 10 issue of the Journal of the American College of Cardiology.