Does Left Ventricular Hypertrophy Affect Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement?
Nimesh Desai, Wilson Y. Szeto, Tyler Wallen, Saif Anwarrudin, Daniel Choudhary, Howard Herrmann, Joseph Bavaria.
University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVE: Severe left ventricular hypertrophy (LVH) has a well documented severe negative impact on early mortality in patients undergoing surgical aortic valve replacement. This effect is particularly pronounced in patients with elevated relative wall thickness, an indicator of extreme hypertrophy with small ventricular cavity(suicide ventricle). It is not clear whether similar mortality risk is present in transcatheter aortic valve replacement(TAVR), which avoids issues regarding myocardial protection and hyperdynamic post-bypass physiology. The purpose of this study is to analyze the impact of LVH on patients undergoing TAVR.
METHODS: From 2008-2011, a retrospective review of patients undergoing tAVR was performed, comparing patients without severe LVH (n=59) to those with severe LVH (group 2, n=89). LVH was defined as a relative wall thickness (2xPosterior wall Thickness/LVEDD) of greater than 0.5. Data was abstracted from a prospectively kept database with robust echocardiograhpic and clinical follow-up.
RESULTS: Preoperative age, STS score, and aortic valve area did not differ (age: 81 vs. 84 years; STS score 12 vs. 12; AVA 0.61 vs. 0.61cm2, no LVH versus severe LVH groups respectively). Peak gradient (PG) was higher in severe LVH group (PG 79 vs. 84mmHg, p<0.0001) but mean gradient (MG) did not differ (MG: 47 vs. 49mmHG, p=NS). The severe LVH group had a higher LV ejection fraction(p<0.001), higher preoperative pulmonary artery pressures(p<0.001), worse mitral and tricuspid regurgitation(p<0.01). There was no difference in peri-procedural mortality (6.8% vs. 7.8%, p=0.5). There were not differences in ventilation time, inotrope use or overall length of stay between groups. At 1 year follow up, mortality rates did not differ (29 vs. 25%, p=0.3). PG and MG did not differ (PG: 23 vs. 24mmH, MG: 12 vs. 12mmHg). LV mass regression did not differ between groups. The severe LVH group continued to have a higher ejection fraction (59 vs. 67%, p<0.001).
CONCLUSIONS: Unlike surgical AVR patients, the presence of severe left ventricular hypertrophy in patients undergoing TAVR was not correlated with adverse outcomes at 1 year.
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