Transapical Transcatheter Aortic Valve Replacement Is Associated With Increased Cardiac Mortality in Patients With Left Ventricular Dysfunction: Insights From the PARTNER I Trial

• Published in: JACC. Cardiovascular interventions Vol. 10; no. 23; p. 2414
• Main Authors: Elmariah, Sammy, Fearon, William F, Inglessis, Ignacio, Vlahakes, Gus J, Lindman, Brian R, Alu, Maria C, Crowley, Aaron, Kodali, Susheel, Leon, Martin B, Svensson, Lars, Pibarot, Philippe, Hahn, Rebecca T, Thourani, Vinod H, Palacios, Igor F, Miller, D Craig, Douglas, Pamela S, Passeri, Jonathan J
• Format: Journal Article
• Language: English
• Published: United States 11.12.2017
• Subjects: Aged; Aged, 80 and over; Aortic Valve - diagnostic imaging; Aortic Valve - physiopathology; Aortic Valve - surgery; Aortic Valve Stenosis - diagnostic imaging; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - physiopathology; Aortic Valve Stenosis - surgery; Chi-Square Distribution; Clinical Decision-Making; Echocardiography; Female; Humans; Kaplan-Meier Estimate; Linear Models; Male; Propensity Score; Proportional Hazards Models; Recovery of Function; Registries; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke Volume; Time Factors; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - methods; Transcatheter Aortic Valve Replacement - mortality; Treatment Outcome; Ventricular Dysfunction, Left - diagnostic imaging; Ventricular Dysfunction, Left - mortality; Ventricular Dysfunction, Left - physiopathology; Ventricular Function, Left; transcatheter aortic valve replacement; transfemoral; left ventricular ejection fraction; transapical; survival
• DOI: 10.1016/j.jcin.2017.09.023
• ISSN: 1876-7605

The authors sought to evaluate the impact of transapical (TA) transcatheter aortic valve replacement (TAVR) on mortality, left ventricular (LV) ejection fraction (LVEF) improvement, and functional recovery in patients with LV dysfunction. LV injury inherent to TA access for structural heart disease interventions may be particularly detrimental to the LV, functional recovery, and survival in patients with LV dysfunction. The study included patients enrolled within the PARTNER I (Placement of Aortic Transcatheter Valves) trial that underwent transfemoral (TF) or TA TAVR. Analyses of clinical outcomes were stratified by the presence of baseline LV dysfunction (LVEF<50%) and adjusted for the propensity of receiving TA TAVR. Of 2,084 subjects, 1,057 underwent TA TAVR. TA access was associated with increased 2-year all-cause mortality in those with (adjusted hazard ratio [HR ]: 1.52; 95% confidence interval [CI]: 1.12 to 2.07; p = 0.008) and without (HR : 1.38; 95% CI: 1.10 to 1.74; p = 0.006) LV dysfunction. TA TAVR portended increased 2-year cardiac mortality in subjects with LVEF<50% (HR : 1.92; 95% CI: 1.21 to 3.05; p = 0.006), but not with LVEF≥50% (HR : 1.29; 95% CI: 0.87 to 1.90; p = 0.21). In those with LVEF<50%, greater improvements in LVEF (TF-TA difference +4.04%, 95% CI: 2.39% to 5.69%; p < 0.0001) and 6-min walk distance (TF-TA difference +45.1 m, 95% CI: 18.4 to 71.9 m; p = 0.001) occurred within 30 days after TF versus TA TAVR. Compared with TF TAVR, TA TAVR is associated with a disproportionate risk of cardiac mortality in patients with LV dysfunction and with delayed and less robust improvement in LV function and overall functional status. Caution is warranted when considering TA access for structural heart disease interventions, particularly in patients with LV dysfunction. (Placement of Aortic Transcatheter Valves [PARTNER]; NCT00530894).