Association between early left ventricular ejection fraction improvement after transcatheter aortic valve replacement and 5-Year clinical outcomes

1. In this retrospective cohort study, left ventricular ejection fraction (LVEF) improvement at 30 days and 1 year was linked with lower 5-year all cause death in patients with severe aortic stenosis (AS) and known left ventricular (LV) dysfunction treated with transcatheter aortic valve replacement (TAVR).

Evidence Rating Level: 2 (Good)

In patients with symptomatic severe aortic stenosis, TAVR is a safe and effective treatment, including those with left ventricular systolic dysfunction. TAVR has been previously found to improve LV ejection fraction by 30 days in approximately half of the patients studied. Failure to improve LVEF has been reported to be linked to an increased risk of 1-year mortality and rehospitalization after TAVR, but these previous studies were quite limited, and the association with LVEF improvement and outcomes remains controversial. This retrospective cohort study collected data from patients at high or intermediate surgical risk in the Placement of Aortic Transcatheter Valves (PARTNER) 1, 2, and S3 trials between July 2007 and April 2015. 659 patients with symptomatic severe AS at high or intermediate surgical risk with a baseline LVEF < 50% that underwent a transfemoral TAVR were included in the study. LVEF was found to improve by 10% points of greater at 30 days post TAVR in 216 patients (32.8%). With respect to the primary outcome, all-cause death within 5 days was lower in patients with early LVEF improvement (P=.04). Specifically, patients with LVEF improvement had a significantly decreased rate of cardiac death (P=.05), but similar rates of noncardiac death and rehospitalization. In addition, LVEF improvement at 1 year was linked with significantly lower 5-year all-cause death, cardiac death, all-cause death or rehospitalization, and cardiac death or rehospitalization. With respect to other secondary outcomes, there was no significant difference between patients with and without LVEF improvement in NYHA functional class or Kansas City Cardiomyopathy Questionnaire (KCCQ). Interestingly, in subgroup analyses, a significant interaction by sex was reported such that early LVEF improvement was linked with significantly improved outcomes in females but not in males. Overall, this study reports that LVEF improvement at 30 days and at 1 year are linked with significantly lower 5-year all cause death.  Further studies into the association of certain risk factors with mortality may be imperative to guide management decisions of severe AS with LV dysfunction in the future. Unfortunately, limitations of this study include exclusion of certain population groups from the original database, including those with severe LV dysfunction (LVEF<20%), as well as unknown etiology of LVEF; patients with LV dysfunction due to causes other than valvular heart disease may not experience LVEF improvement after treatment of AS.

Click to read the study in JAMA Cardiology

Image: PD

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