146 Adverse impact of pre-therapeutic gradient on outcome in patients with trans-aortic valve implantation: a monocentric experience

Abstract

Although trans aortic valve implantation (TAVI) is a promising alternative solution for patients who could not undergo conventional surgery, few data are available regarding post-procedure complications among these fragile subjects. We sought to evaluate the factors associated with adverse outcome in patients with TAVI. Clinical, biological and echocardiographic characteristics of the patients were assessed before implantation. Patients were followed up to 30 days after procedure. Our main primary end-point was the composite of death+stroke+acute pulmonary edema at day 30. Between November 2008 and March 2010, n = 55 patients underwent TAVI in our institution (mean age = 84.4 ± 0.7 y; 40% men; mean STS score = 25.2 ± 1.3; 65% transfemoral). Primary endpoint occured in n = 9 subjects (n = 2 deaths; n = 1 stroke; n = 6 pulmonary edema), who presented a longer inhospital stay (14.4 ± 3.2 vs. 9.2 ± 0.6 days, p = 0.008). Patients experiencing the primary endpoint were comparable to the others in terms of age, gender, renal function, comorbidities, type of percutaneous approach and STS score. The pre-implantation aortic gradient was lower in patients with adverse outcome (35.9 ± 4.0 vs. 55.0 ± 2.9 mmHg, p = 0.007), yet the left ventricle ejection fraction (LVEF/56.4 ± 1.9 vs. 58.4 ± 6.0%, p = 0.7) and effective orifice area (0.43 ± 0.03 vs. 0.37 ± 0.02 cm2/m2, p = 0.12) did not significantly differ between the é groups. Among these patients, n = 7 had LVEF>50%. Receiver operating curve analysis showed a significant relationship between aortic gradient and primary end-point (AUC = 0.82 ± 0.07, p = 0.002). Multivariate analysis identified presence of a low trans-aortic gradient (<40 mmHg) as the sole predictor of primary endpoint (HR = 9.3 [1.9–45.0], p = 0.006). Patients with baseline low trans aortic gradient, as a result of either altered LVEF or paradoxical low flow aortic stenosis syndrome, have a higher incidence of major complications after TAVI and should be identified before procedure.