Transcatheter aortic valve implantation in acute decompensated aortic stenosis

Abstract

Objectives To assess the safety and efficacy of first‐line transcatheter aortic valve implantation (TAVI) in patients presenting with acute decompensated aortic stenosis (ADAS). Background ADAS is common and is often treated medically or using balloon aortic valvuloplasty in the first instance. This temporizing measure results in suboptimal outcomes. In the current era, TAVI provides an alternative option. Methods Consecutive patients who had either a TAVI for ADAS or electively were included in the study. The primary outcome was procedural and 30‐day mortality and hospital length of stay (LOS). Secondary outcomes included 1‐year mortality and procedural complications. Results Of note, 893 patients (mean age 83 ± 7, 50.5% male) underwent TAVI (19% ADAS, 81% elective). ADAS patients were more unwell with worse echocardiographic parameters than elective patients. ADAS patients of 55.9% were known to have significant aortic stenosis prior to their decompensation. Procedural mortality was not different between the ADAS and elective cohorts (1.2 vs. 0.7%; p = .62). The ADAS cohort had a higher 30‐day mortality (5.3 vs. 1.1%; p = .002) and longer LOS (31.9 ± 20.7 days vs. 6.1 ± 6.5 days; p < .001). Multivariate analysis identified acute kidney injury and ADAS as significant predictors of 30‐day mortality. Conclusions TAVI for ADAS is safe and effective with procedural outcomes similar to elective patients. However, compared to elective patients, they have worse physiological baseline features, poorer prognosis at 30 days, and longer hospital admissions. Majority of patients who presented with ADAS were known to have AS prior to admission.

Prevalence and predictive value of fluid overload in patients with severe symptomatic aortic valve stenosis

“…The association of fluid overload and increased risk of adverse outcomes has been debated and leaves us with some unanswered questions. Previous studies showed that procedural outcomes were similar in decompensated patients, but they had poorer prognoses at 30 days and longer time of hospitalizations 5,6 Pre‐TAVI fluid overload is important and strongly related to post‐TAVI outcomes.…”

“…Previous studies showed that procedural outcomes were similar in decompensated patients, but they had poorer prognoses at 30 days and longer time of hospitalizations. 5,6 • Pre-TAVI fluid overload is important and strongly related to post-TAVI outcomes. These data suggest to be cautious in applying TAVI in patients with severe fluid overload.…”

Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity

“…Although TAVI has been performed safely in these patients, outcomes are worse than patients without decompensation; at 1 year post-TAVI, mortality is between 15.3 and 29.1%. [ 78 – 80 ] Traditional markers of futility described above predict mortality in ADAS: AF, oxygen-dependent lung disease, low body surface area (a marker of sarcopenia/malnutrition), previous cardiac surgery and poor renal function. [ 80 ] However, there is a large degree of overlap in baseline characteristics between ADAS and non-ADAS patients, making it challenging to differentiate and, therefore, predict futility.…”

Preprocedural Prognostic Factors in Acute Decompensated Aortic Stenosis

“…Despite advances in our understanding of the natural history of aortic stenosis (AS), identification of novel prognostic markers 1 and development of risk stratification tools 2 , many AS patients present with acute decompensation (ADAS)-characterised by severe symptoms warranting hospital admission and urgent aortic valve replacement. Our ability to predict ADAS is limited, which consequently accounts for 7-23% of all transcatheter aortic valve implantations (TAVI) [3][4][5] . Over the past decade, an increasing number of patients with ADAS are treated with TAVI 6 .…”

“…Anecdottaly, the COVID-19 pandemic has resulted in delays for many patients awaiting elective aortic valve replacement and consequently patients are increasingly presenting with ADAS. Despite TAVI being safe and effective for these patients, mortality remains high; 5.3% at 30 days and 15.3% at 1 year post-TAVI 5 . Symptoms in AS are associated with changes in myocardial structure and function 7 .…”