Predictors of a poor outcome identified
On multivariate analysis, the predictors of events in the CS patients were comorbidities. Despite propensity matching, being on dialysis, having a permanent pacemaker, or having a mechanical assist device were all independent predictors of mortality risk specific to the CS group.
Age and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) score were not predictors.
These risk factors deserve consideration when evaluating CS candidates for TAVR, but Dr. Dhoble said that none are absolute contraindications. Rather, he advised that they should be considered in the context of the entire clinical picture, including the expected benefit from TAVR. Indeed, the benefit-to-risk ratio generally favors TAVR in CS patients, particularly those with obstructive CS caused by aortic stenosis, according to Dr. Dhoble.
“Efforts should be made not only to avoid delaying TAVR in such patients but also to prevent CS by early definitive treatment of patients with aortic stenosis,” he said.
These data are useful and important, said Jonathan Schwartz, MD, medical director, interventional cardiology, Atrium Health, Charlotte, N.C.
CS candidates for TAVR “are some of the sickest patients we treat. It is nice to finally have some data for this group,” he said. He agreed that CS patients can derive major benefit from TAVR if appropriately selected.
While many CS patients are already considered for TAVR, one source of hesitation has been the exclusion of CS patients from major TAVR trials, said Dr. Dhoble. He hopes these data will provide a framework for clinical decisions.
Ironically, the first TAVR patient and half of the initial series of 38 TAVR patients had CS, noted Alain G. Cribier, MD, director of cardiology, Charles Nicolle Hospital, University of Rouen, France. As the primary investigator of that initial TAVR study, conducted more than 20 years ago, he said he was not surprised by the favorable results of the propensity analysis.
“There is an almost miraculous clinical improvement to be achieved when you succeed with the procedure,” said Dr. Cribier, recounting his own experience. Improvements in LVEF of up to 30% can be achieved “within a day or two or even the first day,” he said.
Dr. Dhoble reports financial relationships with Abbott Vascular and Edwards Lifesciences. Dr. Schwartz reports that he has financial relationships with Abbott Vascular, Boston Scientific, Cordis, Edwards Lifesciences and Medtronic. Dr. Cribier reports a financial relationship with Edwards Lifesciences.