Aortic Stenosis Staging Helps Predict TAVR Outcomes

MedicalResearch.com Interview with:
JOÃO L. CAVALCANTE, MD, FASE, FACC, FSCCT, FSCMR
Director, Cardiac MRI and Structural CT Labs
Director, Cardiovascular Imaging Research Core Lab
Minneapolis Heart Institute
Abbott Northwestern Hospital
Minneapolis, MN, 55407

MIHO FUKUI MD
Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota

MedicalResearch.com: What is the background for this study?

Response: Recent study by Généreux et al (1), using the Placement of Aortic Transcatheter Valves (PARTNER) 2A and 2B data, provided the first framework of a staging system for severe aortic stenosis (AS) that quantifies the extent of structural and functional cardiac change associated with AS and importantly its association with 1-year mortality in patients receiving either surgical or transcatheter AVR (TAVR):

  • Stage 0: No other cardiac damage;
  • Stage 1: LV damage as defined by presence of LV hypertrophy, severe LV diastolic, or LV systolic dysfunction;
  • Stage 2: Left atrium or mitral valve damage or dysfunction;
  • Stage 3: Pulmonary artery vasculature or tricuspid valve damage or dysfunction; and
  • Stage 4: right ventricular damage.

MedicalResearch.com: What are the main findings? 

Response: Our findings confirm those by Généreux et al (1) in demonstrating in a large real-world cohort of consecutive TAVR patients that the proposed aortic stenosis staging is associated with a graded relationship with all-cause mortality during long-term two-year follow-up after TAVR. Additionally, we demonstrate, for the first time, this classification is also associated with post-TAVR readmissions for both cardiac and non-cardiac causes. This is the case particularly for those patients with advanced pulmonary hypertension and moderate-severe tricuspid regurgitation.

MedicalResearch.com: What should readers take away from your report? 

Response: This classification is practical and easy to be incorporated into clinical practice for both discussions with the heart team and with the patients. With the potential expansion of TAVR into lower risk cohorts, although the burden of extra-cardiac comorbidities and frailty may be lessened, the importance of comprehensive structural and functional evaluation of pre-TAVR for cardiac change will gain further importance.

            Our findings also suggest that there is an opportunity to plan and evaluate a group of patients undergoing TAVR that could have implications for readmission planning and healthcare costs.

It’s important that we do not preclude a lifesaving therapy such as TAVR, but that we instead raise our awareness that there might be other comorbidities that might be limiting the full benefit of TAVR and to evaluate other strategies that we can do something beyond that. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: Future larger multicenter prospective studies are necessary to validate this new proposed AS staging classification and to test the hypothesis whether the AS staging should be used as a risk stratification and potential timing for aortic valve intervention. 

Disclosures: Dr. Schindler has served on the advisory board of Boston Scientific; and on the speakers’ bureau for Edwards Lifesciences; Dr Gleason has received research funding from Medtronic and Boston Scientific; and has been a consultant for Abbott; Dr Cavalcante has received research funding and consultant fees from Medtronic Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Citations:

  1. Genereux P, Pibarot P, Redfors B, Mack MJ, Makkar RR, Jaber WA, et al. Staging classification of aortic stenosis based on the extent of cardiac damage. Eur Heart J. 2017;38(45):3351-8.
  2. Fukui M, Gupta A, Abdelkarim I, et al. Association of Structural and Functional Cardiac Changes With Transcatheter Aortic Valve Replacement Outcomes in Patients With Aortic Stenosis. JAMA Cardiol.Published online February 06, 2019. doi:10.1001/jamacardio.2018.4830

https://jamanetwork.com/journals/jamacardiology/article-abstract/2723401?resultClick=1

Feb 15, 2019 @ 1:32 pm

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