Prior research has assessed post-transcatheter aortic valve implantation (TAVI) mortality in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and with reduced ejection fraction (HFrEF) but without aortic stenosis (AS). However, studies to determine post-TAVI outcomes and mortality among patients with severe AS and HFrEF or HFpEF are lacking. For a study published in The American Journal of Cardiology, Chayakrit Krittanawong, MD, and colleagues sought to determine the rate of in-hospital mortality in patients treated with TAVI for AS with HFrEF or HFpEF. “To improve technique and prevent serious procedural complications during TAVI, it is crucial to identify the causes of in-hospital mortality among patients undergoing this procedure,” explains Dr. Krittanawong.

Making Comparisons

Dr. Krittanawong and colleagues extracted data from patients hospitalized between 2011 and 2015 with HF who underwent TAVI. Among 11,609 subjects, 54.9% had baseline HF, including 4,290 (67.4%) with HFpEF and 2,078 (32.6%) with HFrEF.

In-hospital mortality occurred in 3.63% of patients undergoing TAVI. Patients with versus without HF had a slightly lower rate of in-hospital mortality (212 of 6,368 [3.33%] vs 209 of 5,241 [3.99%]). “Because of the similar rates of mortality, the presence of HF should not be considered a prohibitive risk to undergo TAVI for severe AS,” notes Dr. Krittanawong. The rate of in-hospital mortality was not significantly different in patients with HFrEF compared with HFpEF (3.66% vs 3.17%).

Predicting In-Hospital Mortality

Identified predictors of in-hospital mortality in patients with HFrEF and HFpEF included hypertension, chronic kidney disease (CKD), permanent pacemakers, electrolyte abnormalities, and coronary artery bypass grafting (Table). Although the majority of predictors were represented in both HFrEF and HFpEF patients, nonaortic valvular heart disease was an independent indicator only in those with HFrEF. In HFpEF, the presence of advanced age, liver disease, depression, and the absence of anemiawere independent indicators.

Future Foresight

Dr. Krittanawong explains that the study was a non-randomized analysis that could not be adjusted for confounders, adding that she and her colleagues, therefore, believe the results should be considered grounds for hypothesis and further research. With knowledge of in-hospital mortality predictors for TAVI possibly benefiting the selection process, physician recommendations, and initiating future studies, she foresees the need for continued research in three key areas:

  1. Evaluating the outcomes of patients with low EF versus preserved EF. This study indicated similar mortality despite patients with low EF having higher pre-surgical mortality.
  2. Confirming and better understanding why patients with HFrEF experienced increased mortality with increasing age, liver disease, depression, and absence of anemia.
  3. Addressing the discrepancy in the ratio of patients with HFrEF versus HFpEF. Although the two groups represent half of the HF patient population, of patients who underwent TAVI, more than 60% had HFpEF.

In the meantime, Dr. Krittanawong recommends that “every patient undergoing TAVI should be meticulously treated and followed up closely by a multidisciplinary team. Additionally, extra precaution is needed in patients with CKD and electrolyte abnormalities periprocedurally.”

References

Predictors of In-Hospital Mortality after Transcatheter Aortic Valve Implantation

https://www.ajconline.org/article/S0002-9149(19)31161-0/fulltext