Aortic valve calcium score as a predictor for outcome after TAVI using the CoreValve revalving system

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Abstract

Background

TAVI is a novel treatment option for patients at too high risk for surgery. Risk scores for surgical valve replacement failed to accurately predict outcomes after TAVI and alternative risk parameters are lacking so far.

Objective

We evaluated the CT-derived aortic valve calcification score as a predictor for outcome during and after TAVI.

Methods

Transfemoral TAVI using the CoreValve device was performed in 68 patients, in whom the aortic valve calcium score was determined from preprocedural 64-sclice ECG gated CT-scans.

Results

30-day MACE rate (death, stroke, MI) was 10.3%, 1-year mortality was 11.8%. Using linear regression analysis the aortic valve calcium score was the only significant predictor for 30-day MACE and for 1-year mortality and was also associated with the incidence and severity of post procedural aortic regurgitation (r = 0.33, p < 0.05). Patients withvalve calcium scores > 750 had a significant lower 1-year survival rate compared to patients with scores < 750 (58% vs. 98%, p < 0.05). The aortic valve calcium score is also inversely associated with the absolute improvement of NYHA-class after TAVI (regression coefficient =  0.43, p < 0.02).

Conclusion

The degree of aortic valve calcification is associated with post procedural aortic regurgitation, procedural complications, 1-year mortality and with the degree of functional improvement of patients who underwent TAVI using the CoreValve device. Due to the fact that the aortic valve calcium score can be determined from CT-datasets that are used for preprocedural planning, this parameter may be incorporated in the general work up and may be used for risk stratification and patient selection.

Introduction

In the ageing population of industrialized nations, degenerative aortic stenosis is the most common native valve disorder. Surgical aortic valve replacement has excellent clinical outcomes but there is an increasing number of patients with severe aortic stenosis who are not considered surgical candidates, because of significant co-morbidity. In these patients catheter-based approaches for valve replacement show promising initial results [[1], [2], [3], [4], [5], [6], [7], [8]]. Fatal complications of TAVI like stroke, myocardial infarction, aortic dissection, cardiogenic shock or death are reported in up to 10% of patients [[9], [10], [11], [12], [13], [14]]. To date no powerful predictive clinical parameters or risk scores are known that would allow an individual risk stratification for procedural complications and long-term outcome [8]. Such predictors however would facilitate pre-procedural planning and would help to better compare the effectiveness of different devices and implantation strategies in various patient cohorts.

For the demanding TAVI procedure preinterventional anatomical information is mandatory for planning and proper device selection [[15], [16], [17], [18], [19]]. Multi Slice CT is increasingly used to determine dimensions of the aorta at different locations and may serve as an alternative to transthoracic and transesophageal echocardiography for assessing dimensions of the aortic annulus, which is critical for selection of the device size [20]. In addition to these parameters MSCT allows to accurately detect, localize and quantify aortic valve calcification and it has been demonstrated that the amount of aortic valve calcium is associated with unfavorable prognosis [21]. Due to the significant heterogeneity of amount and location of aortic valve calcification it may also influence the success of percutaneous valve implantation. In the present study we therefore sought to evaluate aortic valve calcification as a predictor for procedural complications and 1-year outcome after implantation of the CoreValve revalving system (CVRS).

Section snippets

Ethics statement

All patients gave written informed consent to be treated by that procedure and for preinterventional imaging. The local ethics committee of the chamber of physicians in Bavaria approved the protocol as a post procedure surveillance registry.

Patients

From June 2008 till August 2009 we recruited 69 consecutive patients suitable for transfemoral TAVI due to severe and symptomatic aortic stenosis. In an interdisciplinary conference consisting of cardiologists and cardiac surgeons all these patients were

Results

In the current study we included 69 consecutive patients who underwent transfemoral TAVI and preprocedural MSCT. Patient characteristics of the included patients are given in Table 1.

Based on the CT-measurements patients received either the 26 mm Device (n = 41) or the 29 mm device (n = 27).

Discussion

TAVI is a new therapy to treat severe aortic stenosis in patients with no option for surgery. In the first trials a remarkable success rate and an impressive survival rate was demonstrated [7]. Although parameters predicting procedural risk and mortality would be very helpful for improved patient selection, powerful predictors or prediction models are not well known yet. Surgical risk scores like the log Euro score or the STS-score are suitable for selecting candidates for TAVI, they failed

Acknowledgments

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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    AW. Leber and M. Kasel contributed equally to the study.

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