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Randomized Controlled Trial
. 2017 Dec 11;10(23):2414-2422.
doi: 10.1016/j.jcin.2017.09.023.

Transapical Transcatheter Aortic Valve Replacement Is Associated With Increased Cardiac Mortality in Patients With Left Ventricular Dysfunction: Insights From the PARTNER I Trial

Sammy Elmariah  1 , William F Fearon  2 , Ignacio Inglessis  3 , Gus J Vlahakes  4 , Brian R Lindman  5 , Maria C Alu  6 , Aaron Crowley  6 , Susheel Kodali  7 , Martin B Leon  7 , Lars Svensson  8 , Philippe Pibarot  9 , Rebecca T Hahn  7 , Vinod H Thourani  10 , Igor F Palacios  3 , D Craig Miller  2 , Pamela S Douglas  11 , Jonathan J Passeri  3 ; PARTNER Trial Investigators and PARTNER Publications Office
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Free article
Randomized Controlled Trial

Transapical Transcatheter Aortic Valve Replacement Is Associated With Increased Cardiac Mortality in Patients With Left Ventricular Dysfunction: Insights From the PARTNER I Trial

Sammy Elmariah et al. JACC Cardiovasc Interv. .
Free article

Abstract

Objectives: The authors sought to evaluate the impact of transapical (TA) transcatheter aortic valve replacement (TAVR) on mortality, left ventricular (LV) ejection fraction (LVEF) improvement, and functional recovery in patients with LV dysfunction.

Background: LV injury inherent to TA access for structural heart disease interventions may be particularly detrimental to the LV, functional recovery, and survival in patients with LV dysfunction.

Methods: The study included patients enrolled within the PARTNER I (Placement of Aortic Transcatheter Valves) trial that underwent transfemoral (TF) or TA TAVR. Analyses of clinical outcomes were stratified by the presence of baseline LV dysfunction (LVEF<50%) and adjusted for the propensity of receiving TA TAVR.

Results: Of 2,084 subjects, 1,057 underwent TA TAVR. TA access was associated with increased 2-year all-cause mortality in those with (adjusted hazard ratio [HRadjusted]: 1.52; 95% confidence interval [CI]: 1.12 to 2.07; p = 0.008) and without (HRadjusted: 1.38; 95% CI: 1.10 to 1.74; p = 0.006) LV dysfunction. TA TAVR portended increased 2-year cardiac mortality in subjects with LVEF<50% (HRadjusted: 1.92; 95% CI: 1.21 to 3.05; p = 0.006), but not with LVEF≥50% (HRadjusted: 1.29; 95% CI: 0.87 to 1.90; p = 0.21). In those with LVEF<50%, greater improvements in LVEF (TF-TA difference +4.04%, 95% CI: 2.39% to 5.69%; p < 0.0001) and 6-min walk distance (TF-TA difference +45.1 m, 95% CI: 18.4 to 71.9 m; p = 0.001) occurred within 30 days after TF versus TA TAVR.

Conclusions: Compared with TF TAVR, TA TAVR is associated with a disproportionate risk of cardiac mortality in patients with LV dysfunction and with delayed and less robust improvement in LV function and overall functional status. Caution is warranted when considering TA access for structural heart disease interventions, particularly in patients with LV dysfunction. (Placement of Aortic Transcatheter Valves [PARTNER]; NCT00530894).

Keywords: left ventricular ejection fraction; survival; transapical; transcatheter aortic valve replacement; transfemoral.

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