Classification System Ties Cardiac Changes to Post-TAVR Outcome

A classification system for the different stages of aortic stenosis may help clinicians select the right patients for transcatheter aortic valve replacement (TAVR), researchers said.

Based on echocardiographic markers of cardiac function, the staging classification system had a graded association with risk of all-cause mortality even after adjustment for STS-PROM over the study's follow-up period (median 20.1 months):

  • Stage 1 (left ventricle damage): reference
  • Stage 2 (left atrial or mitral damage): adjusted HR 1.37 (95% CI 0.81-2.31)
  • Stage 3 (pulmonary artery or tricuspid damage): adjusted HR 2.24 (95% CI 1.28-3.92)
  • Stage 4 (right ventricle damage): adjusted HR 2.83 (95% CI 1.39-5.76)

Those with Stage 3 or 4 disease also had higher odds of cardiac readmissions (HR 1.84, 95% CI 1.13-3.00), reported João Cavalcante, MD, now at Abbott Northwestern Hospital in Minneapolis, and colleagues in JAMA Cardiology.

Researchers who proposed the staging system in 2017 had shown it to be a strong independent predictor of 1-year mortality using PARTNER 2 data.

Now Cavalcante's group confirmed that finding, and showed that staging was linked to all-cause mortality lasting more than a year, as well as associated with post-TAVR readmission.

Their study included 689 consecutive patients with severe aortic stenosis who underwent TAVR at the University of Pittsburgh Medical Center in 2011-2017 (50.9% men; average 82.4), excluding those getting valve-in-valve TAVR. These study participants got a mix of self-expanding (69.1%), balloon-expandable (27.4%), and mechanically expandable valves (3.5%).

Using the staging criteria, Cavalcante and colleagues classified the patients as stage 1 (13%), stage 2 (62%), stage 3 (21%), and stage 4 (4%).

"Whether this proposed staging classification system, bearing its simplifications and limitations, could serve as a framework for monitoring disease progression and making early referral to interventions for patients who start to demonstrate extravalvular cardiac dysfunction will require further study and a larger prospective evaluation," the investigators said.

They noted the limited generalizability of their results given that the study was conducted at a single, high-volume, TAVR center. Additionally, a mix of older- and newer-generation bioprosthetic valves was involved such that outcomes could have been better with later devices.

Cavalcante disclosed support from Medtronic. Co-authors disclosed support from, and relevant relationships with, Medtronic, Edwards Lifesciences, Boston Scientific, and Abbott.


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