Delayed Improvement of Depression and Anxiety after Transcatheter Aortic Valve Implantation (TAVI) in Stages of Extended Extra-Valvular Cardiac Damage

Abstract

Background: Depression and anxiety are frequently occurring and likely to be linked to the severity of cardiac diseases like aortic stenosis (AS). This seems to be of interest since a staging classification of extra-valvular cardiac damage in AS has been introduced and shown to be of prognostic relevance.

Objective: The current study aimed to investigate the frequency of depression and anxiety in association to staging and their dynamics after transcatheter aortic valve implantation (TAVI).

Methods: A total number of 224 AS patients undergoing TAVI were classified according to the 2017 staging classification into stage 0 to 4 and further dichotomized into group A (stage 0 to 2) and B (stage 3 and 4). Using the Hospital Anxiety and Depression Scale (HADS-D), patients were assigned to depressive versus non-depressive or anxious versus non-anxious per staging group respectively, and analyzed at baseline, 6 weeks, 6 months and 12 months after TAVI.

Results: After dichotomization, 158 patients (70.5%) were assigned to group A and 66 patients (29.5%) to group B. The part showing pathologic values for depression was 25.4% (57/224 patients) in the entire collective, 26.6% (42/158 patients) in group A and 22.7% (15/66 patients) in group B (p = n.s.). The proportion showing pathologic values for anxiety was 26.8% (60/224 patients) in the entire collective and did not differ between group A (24.7%, 39/158 patients) and B (31.8%, 21/66 patients) (p = n.s.). In patients revealing pathologic values for depression or anxiety prior to TAVI, there were significant and stable improvements over time observable already in short-term (6 weeks) follow-up in group A, and likewise, but later, in long-term (6/12 months) follow-up in group B.

Conclusions: Although of proven prognostic relevance, higher stages of extra-valvular cardiac damage are not associated with higher rates of pre-existing depression or anxiety. The TAVI procedure resulted in a persisting reduction of depression and anxiety in patients showing pathologic values at baseline. Notably, these improvements are timely delayed in higher stages.

Keywords: anxiety; aortic stenosis; depression; follow-up; staging of extra-valvular cardiac damage; transcatheter aortic valve implantation.

Figure 1

Comparison of extra-valvular cardiac damage staging according to the 2017 staging classification in the Jenaer Aortenklappenregister (JAKR) study cohort presented here (n = 224, light grey) compared to the PARTNER 2 trials cohort (n = 2703, dark grey) showing high levels of consistency.

Figure 2

Dynamics of depression and anxiety after TAVI in the entire collective. Development of depression (a) and anxiety (b) in the depressive subgroup of the entire patients’ collective showing a significant improvement already 6 weeks after TAVI for both depression and anxiety. For depression but not for anxiety, this improvement remained stable even until the 6-month as well as the 12-month follow-up. Development of depression (c) and anxiety (d) in the anxious subgroup of the entire patients’ collective showing no significant changes with respect to depression but a significant reduction of anxiety 6 weeks after TAVI, remaining stable until the 6-month and the 12-month follow-up.

Figure 3

Dynamics of depression and anxiety after TAVI in staging group A. Development of depression (a,c) and anxiety (b,d) in the depressive (a,b) and the anxious (c,d) subgroup of staging group A. In the depressive subgroup, there was a significant and persisting decrease of depression at the 6-week, the 6-month as well as the 12-month follow-up, each compared to baseline (a). In contrast, in these patients, no dynamics with respect to anxiety could be observed (b). In the anxious subgroup, we could also detect a significant and stable decrease of anxiety at the 6-week, the 6-month and at the 12-month follow-up, each compared with baseline (c). When considering depression in these patients, we could not evidence any dynamics over time (d).

Figure 4

Dynamics of depression and anxiety after TAVI in staging group B. Development of depression (a,c) and anxiety (b,d) in the depressive (a,b) and the anxious (c,d) subgroups of staging group B. In the depressive subgroup, a relevant reduction in HADS-D depression values could not yet be detected at the 6-week follow-up but was present at the timepoint of long-term follow-up 6/12 months after TAVI compared to baseline (a). With respect to anxiety, there was an early and persisting decrease at the 6-week as well as the ‘long-term 6/12 months’ follow-up compared to baseline (b). In the anxious subgroup, there were no changes with respect to both depression and anxiety 6 weeks after TAVI. At the ‘long-term 6/12 months’ follow-up’, a significant reduction of anxiety but not depression could be observed compared to baseline (c,d).