Thomas Pilgrim, Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland, and others reported in Circulation: Cardiovascular Interventions that intercurrent events, such as access and bleeding complications (ABC), increase the cumulative risk of stroke and death after TAVI.
Pilgrim et al wrote that the long-term survival after successful TAVI is largely dependent on a patient’s comorbidities and added: “To provide selection criteria for patients to benefit most from TAVI, it is therefore necessary to indentify not only predictors of peri-procedural risk but also of potentially adverse long-term clinical outcomes.”
The authors reported that coexisting morbidities, despite TAVI relieving the mechanical obstruction association with aortic stenosis, “continue to propel the degenerative disease process in a modified way across various transitions. Predictors of transitions in the clinical pathway of disease progression after TAVI during long-term follow-up have not been investigated so far.”
Therefore using multistate analysis (MSA), Pilgrim et al estimated the effective of incurrent events, such as ABC, on the risk of stroke and death in patients with severe aortic stenosis undergoing TAVI. Three hundred and eight nine patients were included in the analysis and the median follow-up time was 1.1 years.
The authors wrote: “42.5% of patients progressed via primary transitions to kidney injury, ABC or stroke and death. Among patients who developed either peri-interventional kidney injury or ABC, 40.5% and 41% died, respectively.” They added that of the four disease stages (TAVI, kidney injury, ABC, stroke/death), five transitions (from one stage to another; three primary, two secondary) were relevant. They explained that transseptal access was a significant predictor of kidney injury and ABC but did not increase the composite risk of stroke and death; that low body mass index (BMI; ≤20Kg/m2) increased the risk of stroke and death; and that age >80 years, prior stroke, and the presence of atrial fibrillation at baseline increased the risk of stroke and death after an incurrent event of ABC.
Pilgrim et al commented: “In the present analysis, we observed a mortality rate comparable to that of the general population only in those patients undergoing TAVI who did not have any incurrent adverse events. Conversely the risk of death increase several fold after intercurrent events such as kidney injury, ABC, or stroke.” They added that the increased risk of stroke and death observed with a low BMI may be because low BMI may be marker of frailty and wrote:“The underlying mechanism of low BMI leading to stroke may be explained by a higher vulnerability of smaller vessels to large-bore instruments or more cautious peri-procedural anticoagulation in underweight patients giving rise to thromboembolic events.”
Concluding, Pilgrim et al stated: “Patients with one or more risk factors [of those observed in the study] deserve careful evaluation and remain at increased risk for morality after TAVI.”
Pilgrim told Cardiovascular News: Our study focuses on the inter-relationship of different events occurring mostly in the peri-procedural phase after TAVI and highlights factors that propel the degenerative disease process to a composite endpoint of stroke or death.It aims to improve the selection of patients who benefit most from TAVI in the long-term.”