Predictors and clinical outcomes of poor symptomatic improvement after transcatheter aortic valve replacement

Abstract

Objective: Transcatheter aortic valve replacement (TAVR) improves clinical symptoms in most patients with severe aortic stenosis (AS). However, some patients do not benefit from the symptom-reducing effects of TAVR. We assessed the predictors and clinical outcomes of poor symptomatic improvement (SI) after TAVR.

Methods: A total of 1749 patients with severe symptomatic AS undergoing transfemoral TAVR were evaluated using the Japanese multicentre TAVR registry. Poor SI was defined as readmission for heart failure (HF) within 1 year after TAVR or New York Heart Association (NYHA) class ≥3 after 1 year. A logistic regression model was used to identify predictors of poor SI. One-year landmark analysis after TAVR was used to evaluate the association between poor SI and clinical outcomes.

Results: Among the overall population (mean age, 84.5 years; female, 71.3%; mean STS score, 6.3%), 6.6% were categorised as having poor SI. Atrial fibrillation, chronic obstructive pulmonary disease, Clinical Frailty Scale ≥4, chronic kidney disease and moderate to severe mitral regurgitation were independent predictors of poor SI. One-year landmark analysis demonstrated that poor SI had a higher incidence of all-cause death and readmission for HF compared with SI (p<0.001). Poor SI with preprocedural NYHA class 2 had a worse outcome than SI with preprocedural NYHA class ≥3.

Conclusions: Poor SI was associated with worse outcomes 1 year after the procedure. It had a greater impact on clinical outcomes than baseline symptoms. TAVR may be challenging for patients with many predictors of poor SI.

Trial registration number: This registry, associated with the University Hospital Medical Information Network Clinical Trials Registry, was accepted by the International Committee of Medical Journal Editors (UMIN-ID: 000020423).

Keywords: aortic valve stenosis; heart failure; transcatheter aortic valve replacement.

Figure 1

Distribution of preprocedural and postprocedural New York Heart Association (NYHA-pre) classes and postprocedural readmission for heart failure (HF) each number shows the number of patients with a pair of scores for the NYHA class before and 1 year (NYHA-1y) after transcatheter aortic valve replacement (TAVR) or readmission for HF within 1 year after TAVR. The overall population was divided into two groups: symptomatic improvement (SI), (green +blue) and a poor SI (red +yellow) or four groups, with the subgroups of SI with NYHA-pre 2 (blue), SI with NYHA-pre ≥3 (green), poor SI with NYHA-pre 2 (yellow) and poor SI with NYHA-pre ≥3 (red).

Figure 2

Cumulative incidence of all-cause death and readmission for heart failure from the first postprocedural year according to symptomatic improvement (SI) time-to-event curves are shown from 1 to 2 years for all-cause death (A) and readmission for heart failure (B). Event rates were calculated using the Kaplan-Meier method and compared with the log-rank test.

Figure 3

Cumulative incidence of all-cause death and readmission for heart failure from the first postprocedural year according to preprocedural New York Heart Association (NYHA) functional class and symptomatic improvement (SI) time-to-event curves are shown from 1 to 2 years for all-cause death (A) and readmission for heart failure (B). Event rates were calculated using the Kaplan-Meier method and compared with the log-rank test.