American College of Cardiology

American College of Cardiology

April 07, 2017
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RV dysfunction after AVR linked to worse outcomes

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WASHINGTON — Right ventricular dysfunction is more common after surgical aortic valve replacement, as compared with transcatheter aortic valve replacement, and is linked to an increased risk for death in patients with either type of AVR, a researcher reported at the American College of Cardiology Scientific Session.

In their study, Paul C. Cremer, MD, of the Heart and Vascular Center at the Cleveland Clinic, and colleagues assessed the prevalence of RV dysfunction and its relationship with cardiac and all-cause mortality among patients who underwent TAVR or surgical AVR in the multicenter PARTNER 2A trial.

Overall, RV dysfunction occurred in 15.8% of the entire cohort and was more common after surgical AVR than TAVR (24.3% vs. 8.4%; P < .001). Results from multivariable analysis also showed that patients who underwent TAVR vs. surgical AVR were less likely to develop worsening RV function (OR = 0.25; 95% CI, 0.16-0.41). In addition, patients with moderate tricuspid regurgitation were more likely to have worsening RV function (OR = 3.29; 95% CI, 1.59-6.77).

Between 30 days and 2 years, 58 cardiac events occurred. Cardiac mortality was higher among patients who developed worsening RV function vs. those who did not in both the TAVR (11.8% vs. 5.1%) and surgical AVR groups (12% vs. 5.7%), according to Cremer. However, he noted that there were no statistically detectable differences between those groups when comparing TAVR with surgical AVR in the cohorts with and without RV dysfunction.

Additionally, between 30 days and 2 years, 104 all-cause deaths occurred. Similarly, patients who developed worsening RV function had higher all-cause mortality in the TAVR (21.4% vs. 11.3%) and surgical AVR groups (18.4% vs. 10.9%).

In baseline models that included worsening tricuspid regurgitation, RV systolic pressure, initial RV function, mitral regurgitation, worsening RV function was associated with increased risk for cardiac and all-cause mortality. Worsening tricuspid regurgitation was also linked to increased risk for cardiac and all-cause death.

Degree of worsening RV function also appeared to be associated with adverse outcomes.

“It’s important to note that in patients who start with normal [RV] function and develop mild dysfunction still have a statistically significant increased hazard of cardiac death,” Cremer said. “However, patients who do the worst are those who start with normal [RV] function at baseline and develop moderate to severe [RV] dysfunction at 30 days.”

He noted that results were similar for all-cause death.

In an exploratory analysis, the researchers found that patients who needed a pacemaker after undergoing TAVR were significantly more likely to develop worsening [RV] function. A similar trend was observed among patients who underwent surgical AVR as well, Cremer reported.

“The main take-home message from this study is that [RV] dysfunction after AVR is relatively common — around 15% in this cohort — and it has important prognostic implications,” Cremer said. “For future studies, we need to do more work to figure out why some patients develop [RV] dysfunction and some do not.” – by Melissa Foster

Reference:

Cremer P. Abstract 903-14. Presented at: American College of Cardiology Scientific Session; March 17-19, 2017; Washington, D.C.

Disclosure: The PARTNER 2A trial was sponsored by Edwards Lifesciences. Cremer reports no relevant financial disclosures.