STEMI after TAVR tied to risk for poor outcomes
Among patients with STEMI, prior transcatheter aortic valve replacement was associated with high rates of poor in-hospital and midterm clinical outcomes, according to a study published in the Journal of the American College of Cardiology.
“Longer door-to-balloon times and a higher PCI failure rate were observed in TAVR patients, partially due to coronary access issues specific to the TAVR population, and this was associated with poorer outcomes,” Laurent Faroux, MD, with the Centre Hospitalier Universitaire de Reims, France, and colleagues wrote.
The researchers analyzed 118 patients presenting with STEMI who previously had TAVR and compared them with 439 patients who had STEMI but no prior TAVR, matched by time of procedure. In the TAVR group, STEMI occurred at a median of 255 days (interquartile range [IQR], 9-680) after TAVR.
According to the researchers, median door-to-balloon time was 40 minutes in the TAVR group (IQR, 25-57) and 30 minutes in the non-TAVR group (IQR, 25-30; P = .003). A door-to-balloon time of 60 minutes or more occurred in 20.8% of the TAVR group and 8.6% of patients in the non-TAVR group (P = .005).
The median door-to-balloon time was higher in the TAVR group despite the median time from symptom onset to hospital arrival being lower (P = .015), the researchers wrote.
In the analysis, procedural time, fluoroscopy time, dose-area product and contrast volume were also elevated in patients assigned TAVR (P < .01 for all), and PCI failure occurred more frequently in patients with previous TAVR (16.5% vs. 3.9%; P < .001).
The researchers wrote that the longer door-to-balloon times and higher PCI failure rate were “partially due to coronary access issues specific to the TAVR population.”
In the TAVR group, 25.4% of patients died in the hospital (20.6% of those who had primary PCI) and 42.4% of patients died at a median of 7 months (IQR, 1-21) after hospitalization.
In a multivariable analysis, estimated glomerular filtration rate less than 60 mL/min (HR = 3.02; 95% CI, 1.42-6.43; P = 0.004), Killip class of at least 2 (HR = 2.74; 95% CI: 1.37-5.49; P = .004) and PCI failure (HR = 3.23; 95% CI, 1.42-7.31; P = .005) were associated with increased risk for death.
The researchers found that rates of in-hospital stroke and acute kidney injury were 6.8% and 12.7%, respectively, and at discharge, most patients were given dual antiplatelet therapy (62.5%) or a combination of oral anticoagulants and antiplatelets (31.8%).
“As of today, the optimal timing of coronary artery revascularization in candidates for TAVR remains controversial, but in the setting of STEMI in a post-TAVR patient, primary PCI, despite all its technical difficulties and challenges, should still be the treatment of choice,” Luis Gruberg, MD, and Puneet Gandotra, MD, both interventional cardiologists at South Shore University Hospital, Northwell Health, and professors at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, wrote in a related editorial.
- Gruberg L, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.03.300.