Post-TAVR echocardiography helps predict a patient’s long-term risk of SVD
Higher postprocedural gradients after transcatheter aortic valve replacement (TAVR) are independently associated with a heightened risk of structural valve deterioration (SVD), according to new data published in EuroIntervention.[1] In addition, researchers noted, SVD significantly increases a patient’s long-term risk of all-cause mortality or cardiovascular mortality.
“A key component of valve durability is SVD, which implies intrinsic and structural changes of bioprosthetic leaflets including wear and tear, leaflet disruption, flail, fibrosis, calcification, or strut fracture or deformation in association with progressive hemodynamic valve deterioration,” wrote first author Tullio Palmerini, MD, an associate professor with the University of Bologna in Italy, and colleagues. “Understanding the mechanistic underpinnings of SVD is of the utmost importance for patient risk stratification, implementation of appropriate therapeutic strategies, and lifetime management of younger patients. Despite its clinical relevance, there are scant data on the predictors and prognostic correlates of SVD.”
Palmerini et al. tracked data from more than 1,000 TAVR patients who underwent treatment from September 2007 to December 2014. All patients received a CoreValve/Evolut valve from Medtronic and underwent follow-up echocardiography within 90 days. In total, 3.6% of patients went on to develop SVD.
The authors found that Doppler-derived early residual mean postprocedural gradient (ERMPG) was an independent predictor of SVD, even after correcting for potential confounders. The median ERMPG was higher for patients who developed SVD (10 mm Hg) than it was for patients who did not develop SVD (8 mm Hg). Meanwhile, patients with an ERMPG of less than 6 mm Hg faced the lowest risk of developing SVD.
The group also noted that there was “no significant association” between ERMPG and all-cause mortality or cardiovascular mortality. When following each patient for at least 10 years, however, it became clear that the individuals who developed SVD did experience much worse patient outcomes than those who did not develop SVD. Even after correcting for potential confounders, SVD was confirmed to be an independent predictor of all-cause mortality and cardiovascular mortality. Other independent predictors of all-cause mortality included age, chronic kidney disease, diabetes, pulmonary hypertension and chronic obstructive pulmonary disease (COPD). Other independent predictors of cardiovascular mortality included diabetes, pulmonary hypertension and COPD.
“This is the first study to show an association between ERMPG and SVD after TAVR,” the authors wrote. “This finding is consistent with the observation that, in some randomized studies comparing TAVR versus surgical aortic valve replacement, treatments associated with a lower ERMPG were also associated with lower SVD rates.”
Palmerini and colleagues also wrote that care teams can put specific strategies into place to keep a patient’s ERMPG after TAVR lower. This includes using a supra-annular valve when the patient has a small annulus, for example, and “a more liberal use of post-dilation after transcatheter heart valve deployment.”
“Whether these strategies may benefit patients undergoing TAVR deserves confirmation in randomized controlled trials,” the group added.
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.