New data on cardiac damage before and after AVR suggests earlier treatment may be beneficial
Patients with higher levels of extravalvular cardiac damage prior to aortic valve replacement (AVR) face a higher risk of dying within two years of the procedure, according to new findings presented at EuroPCR 2022 in Paris. In addition, researchers noted, if AVR does not lead to improvements in a patient’s extravalvular cardiac damage after one year, it may be a sign of poor two-year outcomes.
The analysis, which was also published simultaneously in the Journal of the American College of Cardiology,[1] is based on data from the PARTNER II and PARTNER 3 trials. Both trials were sponsored by Edwards Lifesciences.
The study’s authors examined data from 1,974 patients who underwent transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for severe aortic stenosis. While 59.8% of patients underwent TAVR, the remaining 40.2% underwent SAVR.
Patients were stratified into one of five different stages based on their extravalvular cardiac damage at baseline. While 6.1% of patients were considered Stage 0 (no extravalvular cardiac damage), 14.5% were Stage 1 (left ventricular damage), 51.4% were Stage 2 (left atrial or mitral valve damage), 20.9% were Stage 3 (pulmonary vasculature/tricuspid valve damage) and 7.1% were Stage 4 (right ventricular damage).
One year after AVR, significant extravalvular cardiac damage improvements were seen in 15.6% of the entire patient population. Another 26.5% of patients actually saw cardiac damage worsen
Overall, the authors found, the extent of cardiac damage seen at baseline and after one year was directly associated with two-year mortality. Two-year mortality was 2.5% among Stage 0 patients, 7.1% among Stage 1 patients, 14.6% among Stage 2 patients, 28.2% among Stage 3 patients and 28.2% among Stage 4 patients. The same trend was seen when considering the composite of mortality and heart failure hospitalizations after two years.
Presenting with hypertension was found to be an independent predictor of stage deterioration, the authors added. Undergoing SAVR, as opposed to TAVR, was also an independent predictor of stage deterioration.
When should aortic valve replacement be considered for patients with severe aortic stenosis?
The team behind this analysis noted that their findings have “important implications for the timing of valve replacement.”
“Current guidelines recommend waiting for the onset of symptoms prior to consideration of AVR for patients with severe AS,” wrote first author Philippe Généreux, MD, an interventional cardiology and structural heart disease specialist with Morristown Medical Center in New Jersey, and colleagues. “Few patients demonstrate regression of cardiac damage after AVR, however, intervention before the AS reaches a severe and symptomatic state could potentially limit the extent of cardiac damage, thus leading to improved long-term outcomes.”
The team also highlighted the potential impact of “more aggressive management of extravalvular cardiac damage and its underlying causes after AVR.”
Généreux is involved with an ongoing trial using TAVR in patients with AS who are not yet symptomatic, which will likely answer the question if earlier intervention is the key to better outcomes.
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.