In the Journals

LV diastolic dysfunction common in patients undergoing TAVR

 Advancing stages of left ventricular diastolic dysfunction may be linked to all-cause mortality after transcatheter aortic valve replacement, according to data published in JACC: Cardiovascular Interventions.

According to the study, these incremental risks may be driven by CV death and may affect patients as early as 30 days after the intervention.

“TAVR has rapidly evolved as a definitive treatment option for patients with symptomatic severe [aortic stenosis] deemed at an increased surgical risk. Hospital readmission during the first year after TAVR is associated with a significant increase in the risk of death,” Masahiko Asami, MD, from the department of cardiology at the Swiss Cardiovascular Center, Bern University Hospital, Switzerland, and colleagues wrote. “The most common reason for rehospitalization in this patient population is heart failure. LV [diastolic dysfunction] may be an important factor to sustain heart failure after TAVR, since normalization of diastolic stiffness and relaxation due to regression of muscular and non-muscular tissue may be delayed or irreversible.”

According to Asami and colleagues, the analysis was done because there is conflicting evidence on the impact of LV diastolic dysfunction on clinical outcomes after TAVR.

The cohort had 777 consecutive patients with aortic stenosis undergoing TAVR.

The researchers categorized LV diastolic dysfunction according to the latest guidelines. The primary endpoint was 1-year all-cause mortality.

Mortality differences

LV diastolic dysfunction was observed in 70.1% of patients (grade I, 18%; grade II, 36.3%; grade III, 19.1%; undetermined grade, 26.6%).

All-cause mortality at 1 year was higher among patients with LV diastolic dysfunction grade I (16.3%; adjusted HR = 2.32; 95% CI, 1.15-4.66), II (17.9%; aHR = 2.58, 95% CI, 1.43-4.67) and III (27.6%; aHR = 4.21; 95% CI, 2.25-7.86) than among those with normal diastolic function (6.9%).

The mortality difference, which was driven by CV death and maintained in a sensitivity analysis of patients with normal systolic LV function, emerged by 30 days, the researchers wrote.

The researchers also found that LV diastolic dysfunction grade I (aHR = 2.36; 95% CI, 1.17-4.74), II (aHR = 2.58; 95% CI, 1.42-4.66) and III (aHR = 4.41; 95% CI, 2.37-8.2) were independent predictors of 1-year mortality.

“Treatment of [aortic stenosis] before LV [diastolic dysfunction] has developed may be beneficial. However, optimal timing of TAVR in patients with [aortic stenosis] needs to be investigated in prospective clinical studies,” they wrote.

Timing of procedure

In an accompanying editorial, Patricia A. Pellikka, MD, and Ratnasari Padang, MBBS, PhD, from the department of cardiovascular disease at the Mayo Clinic in Rochester, Minnesota, wrote that “potentially life-saving treatments such as TAVR must be administered before it’s too late. AVR should occur prior to the development of myocyte death, myocardial fibrosis and advanced [diastolic dysfunction] which attenuate the long-term benefit of valve replacement.

“Echocardiography, a safe, noninvasive, widely available tool, will continue to play a central role in guiding therapeutic decisions; continued refinements to echocardiographic assessment of cardiac function will enhance our care of patients with [aortic stenosis],” they wrote. – by Dave Quaile

Disclosures: Asami, Pellikka and Padang report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

 

 Advancing stages of left ventricular diastolic dysfunction may be linked to all-cause mortality after transcatheter aortic valve replacement, according to data published in JACC: Cardiovascular Interventions.

According to the study, these incremental risks may be driven by CV death and may affect patients as early as 30 days after the intervention.

“TAVR has rapidly evolved as a definitive treatment option for patients with symptomatic severe [aortic stenosis] deemed at an increased surgical risk. Hospital readmission during the first year after TAVR is associated with a significant increase in the risk of death,” Masahiko Asami, MD, from the department of cardiology at the Swiss Cardiovascular Center, Bern University Hospital, Switzerland, and colleagues wrote. “The most common reason for rehospitalization in this patient population is heart failure. LV [diastolic dysfunction] may be an important factor to sustain heart failure after TAVR, since normalization of diastolic stiffness and relaxation due to regression of muscular and non-muscular tissue may be delayed or irreversible.”

According to Asami and colleagues, the analysis was done because there is conflicting evidence on the impact of LV diastolic dysfunction on clinical outcomes after TAVR.

The cohort had 777 consecutive patients with aortic stenosis undergoing TAVR.

The researchers categorized LV diastolic dysfunction according to the latest guidelines. The primary endpoint was 1-year all-cause mortality.

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Mortality differences

LV diastolic dysfunction was observed in 70.1% of patients (grade I, 18%; grade II, 36.3%; grade III, 19.1%; undetermined grade, 26.6%).

All-cause mortality at 1 year was higher among patients with LV diastolic dysfunction grade I (16.3%; adjusted HR = 2.32; 95% CI, 1.15-4.66), II (17.9%; aHR = 2.58, 95% CI, 1.43-4.67) and III (27.6%; aHR = 4.21; 95% CI, 2.25-7.86) than among those with normal diastolic function (6.9%).

The mortality difference, which was driven by CV death and maintained in a sensitivity analysis of patients with normal systolic LV function, emerged by 30 days, the researchers wrote.

The researchers also found that LV diastolic dysfunction grade I (aHR = 2.36; 95% CI, 1.17-4.74), II (aHR = 2.58; 95% CI, 1.42-4.66) and III (aHR = 4.41; 95% CI, 2.37-8.2) were independent predictors of 1-year mortality.

“Treatment of [aortic stenosis] before LV [diastolic dysfunction] has developed may be beneficial. However, optimal timing of TAVR in patients with [aortic stenosis] needs to be investigated in prospective clinical studies,” they wrote.

Timing of procedure

In an accompanying editorial, Patricia A. Pellikka, MD, and Ratnasari Padang, MBBS, PhD, from the department of cardiovascular disease at the Mayo Clinic in Rochester, Minnesota, wrote that “potentially life-saving treatments such as TAVR must be administered before it’s too late. AVR should occur prior to the development of myocyte death, myocardial fibrosis and advanced [diastolic dysfunction] which attenuate the long-term benefit of valve replacement.

“Echocardiography, a safe, noninvasive, widely available tool, will continue to play a central role in guiding therapeutic decisions; continued refinements to echocardiographic assessment of cardiac function will enhance our care of patients with [aortic stenosis],” they wrote. – by Dave Quaile

Disclosures: Asami, Pellikka and Padang report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.