Elsevier

The American Journal of Cardiology

Volume 133, 15 October 2020, Pages 105-115
The American Journal of Cardiology

Outcomes of Patients with Severe Aortic Stenosis and Left Ventricular Obstruction Undergoing Transcatheter Aortic Valve Implantation

https://doi.org/10.1016/j.amjcard.2020.07.051Get rights and content

Highlights

  • Left ventricular obstruction (LVO) can present concomitantly in patients with severe AS undergoing TAVI.

  • Despite high rates of LV hypertrophy among patients with severe AS undergoing TAVI, LVO is a relatively uncommon finding.

  • LVO is more likely to develop at the midventricular region than at the LV outflow tract.

  • In a propensity-matched cohort, the presence of pre-TAVI LVO was not associated with worse 1-year outcomes.

Scarce data exist on clinical features and prognosis of patients with severe aortic stenosis (AS), concomitant with left ventricular obstruction (LVO). We aimed to evaluate the prevalence, characteristics, and outcomes in patients with severe AS and LVO undergoing transcatheter aortic valve implantation (TAVI). Consecutive patients with severe AS undergoing TAVI between January 2013 to December 2017 at our institution were included. Significant LVO was defined as resting peak left ventricular (LV) systolic gradient ≥30 mm Hg on pre-TAVI echocardiography. We analyzed the primary composite outcome of all-cause mortality and rehospitalization for heart failure (HHF) at 1-year in patients with LVO and those without LVO in the overall and propensity-matched populations. Among 1,729 patients who underwent TAVI, significant LVO was observed in 31 (1.8%) patients. This group was more likely to be female, had smaller aortic annulus and LV cavity, and received a smaller size of the transcatheter heart valve. The most common phenotype of LV hypertrophy causing LVO was concentric LV hypertrophy (58%), and mid-LV obstruction was more common than LV outflow tract obstruction (77% vs 23%, respectively). After adjustment for baseline differences, the primary outcome was not significantly different between patients with LVO and those without LVO (15% vs 16%, respectively; hazard ratio: 0.83; 95% confidence interval: 0.19 to 3.72; p = 0.809). In conclusion, in patients undergoing TAVI, concomitant LVO was relatively uncommon and occurred more often at mid-LV. The presence of pre-TAVI LVO was not associated with worse outcomes defined as increase all-cause mortality or HHF at 1-year.

Section snippets

Methods

We retrospectively reviewed medical records of consecutive patients with severe AS who underwent TAVI at Cedars-Sinai medical center between January 2013 to December 2017 and included in our TAVI database. We excluded patients if (1) they had preexisting left-sided mechanical or bioprosthetic heart valve, (2) no available pre-TAVI transthoracic echocardiography (TTE) within 6 months prior to the procedure, or (3) if the pre-TAVI TTE image quality was poor. The remaining cohort constituted the

Results

We identified 1756 consecutive patients with severe AS who underwent TAVI during the study period. We excluded patients with prior left-sided mechanical or bioprosthetic heart valve replacement (N = 20), and 7 patients who did not have pre-TAVI TTE within 6 months before TAVI. The remaining 1729 patients constituted our study population. Baseline clinical, echocardiographic, MDCT, and periprocedural characteristics of the overall and matched populations are provided in Tables 1, 2, and 3,

Discussion

We conducted a retrospective observational study to evaluate the prevalence, clinical characteristics, and outcomes in patients with severe AS and concomitant LVO undergoing TAVI. To the best of our knowledge, this is the largest study looking at LVO in this population. The main findings of the present study were as follow: (1) The prevalence of LVO in patients with severe AS who underwent TAVI was low (1.8%). (2) The most common phenotypes of LV hypertrophy causing LVO were concentric LV

Disclosures

Dr. Makkar has received grant support from Edwards Lifesciences Corporation; is a consultant for Abbott Vascular, Cordis, and Medtronic, and holds equity in Entourage Medical. Dr. Chakravarty is a consultant, proctor, and speaker for Edwards Lifesciences and Medtronic; he is a consultant for Abbott Lifesciences, and he is a consultant and speaker for Boston Scientific. Other authors have no conflicts of interest to disclose.

Author Contribution

Danon Kaewkes: Conceptualization, Methodology, Formal analysis, Investigation, Writing -Original Draft. Tomoki Ochiai: Conceptualization, Methodology, Writing - Review & Editing. Nir Flint: Conceptualization, Writing - Review & Editing. Vivek Patel: Investigation, Writing - Review & Editing. Sahar Mahani: Investigation, Writing - Review & Editing. Matthias Raschpichler: Writing - Review & Editing. Sung-Han Yoon: Conceptualization, Writing - Review & Editing. Sabah Skaf: Writing - Review &

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