Combination therapy using trans-catheter aortic valve implantation and adaptive servo-ventilation in patient with aortic stenosis and heart failure

Inadequate Cardiac Unloading Following Transcatheter Aortic Valve Replacement

Background: Although many risk factors have been reported to be associated with poor clinical outcomes following transcatheter aortic valve replacement (TAVR), the implications of inadequate cardiac unloading following TAVR remain unknown. We investigated the prognostic impact of inadequate cardiac unloading following TAVR. Methods and Results: We retrospectively analyzed a cohort of patients with severe aortic stenosis who underwent invasive hemodynamic assessment following TAVR. The impact of inadequate cardiac unloading, defined as an elevated pulmonary capillary wedge pressure (PCWP), on the composite primary endpoint of cardiovascular mortality or heart failure readmission was investigated. Eighty-two patients (median age 86 years; 57 women) were included. Median PCWP following TAVR was 9 mmHg (interquartile range 7-13 mmHg). A higher PCWP tended to be associated with an increased risk of adverse cardiovascular events (adjusted hazard ratio 1.18; 95% confidence interval 0.99-1.41). A cut-off value of PCWP >12 mmHg, calculated by time-dependent receiver operating characteristics analysis, stratified the cumulative incidence of the primary endpoint (2-year incidence of 36% vs. 8%). Uptitration of the diuretic dose was associated with event freedom among those with PCWP >12 mmHg. Conclusions: Inadequate cardiac unloading following TAVR was associated with an increased risk of adverse clinical events. Uptitration of medical therapies to improve cardiac hemodynamics after TAVR may reduce this risk.