Prognostically Significant Myocardial Injury in Patients Undergoing Transcatheter Aortic Valve Replacement

• Published in: Journal of the American Heart Association 2019-07, Vol.8 (14), p.e011889-e011889
• Main Authors: Sharma, Vikram, Dey, Tanujit, Sankaramangalam, Kesavan, Alansari, Shehab A R, Williams, Louis, Mick, Stephanie, Krishnaswamy, Amar, Svensson, Lars G, Kapadia, Samir
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Aortic Valve Stenosis - complications; Aortic Valve Stenosis - surgery; coronary artery disease; Coronary Artery Disease - complications; Female; Humans; left main disease; Male; Mortality; myocardial injury; Myocardial Ischemia - blood; Original Research; Postoperative Complications - blood; Prognosis; Retrospective Studies; transcatheter aortic valve implantation; Transcatheter Aortic Valve Replacement - methods; Troponin T - blood
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.118.011889

Background Troponin elevation occurs commonly in the setting of transcatheter aortic valve replacement (TAVR). There is a lack of information on the extent of troponin elevation post TAVR that is prognostically significant. We assessed the optimal cutoff for post-TAVR troponin T elevation that correlates with long-term mortality. We also examined the relationship between coronary artery disease (CAD) and prognostically significant myocardial injury in TAVR. Methods and Results This is a retrospective, observational single-center study involving patients who underwent TAVR at Cleveland Clinic between 2010 and 2015. Five hundred ten patients were included (mean follow-up of 2.6±1.3 years). Receiver operating characteristic analysis showed that troponin T elevation ≥3× upper limit of normal was the best predictor of long-term mortality post TAVR with area under the curve of 0.57, with transapical TAVR patients excluded. Multivariate analyses confirmed that troponin T elevation ≥3× upper limit of normal was significantly associated with increased long-term mortality post TAVR (hazard ratio 1.57, CI 1.04-2.38, P=0.03). The most common causes for the presence of unrevascularized CAD included the presence of chronic total occlusion in the native/graft vessels (49.7%) and diffuse/complex CAD unsuitable for PCI (24.6%). The presence of unrevascularized CAD and significant left main disease correlated with increased mortality, but not with the presence of prognostically significant myocardial injury. Conclusions Troponin T elevation of ≥3× upper limit of normal is associated with increased long-term mortality after TAVR, except for the transapical approach. This prognostically significant myocardial injury does not appear to be secondary to severe CAD/unrevascularized CAD or left main disease, but rather is associated with other factors such as post-TAVR complications.