Abstract 144 The adverse impact of left ventricular outflow tract calcification in patients with severe aortic stenosis undergoing transfemoral TAVI using second-generation devices

Clin Res Cardiol (2021) DOI DOI https://doi.org/10.1007/s00392-021-01843-w
The adverse impact of left ventricular outflow tract calcification in patients with severe aortic stenosis undergoing transfemoral TAVI using second-generation devices
L. Waldschmidt¹, A. Goßling¹, S. Ludwig¹, M. Linder¹, L. Voigtländer¹, O. Bhadra², D. Grundmann³, A. Schäfer², J. Schirmer², H. Reichenspurner², S. Blankenberg³, D. Westermann¹, M. Seiffert⁴, L. Conradi², N. Schofer¹, für die Studiengruppe: HARbOR
¹Allgemeine und Interventionelle Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; ²Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; ³Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; ⁴Klinik und Poliklinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg;
INTRODUCTION Left ventricular outflow tract (LVOT) calcification is known to be associated with adverse outcomes after TAVI in patients receiving 1^st generation transcatheter heart valves (THV). Use of 2^ndgeneration THV has been shown to improve outcomes in TAVI patients. Aim of the present study is to assess the prevalence of LVOT calcification as well as its impact on clinical outcomes in patients undergoing transfemoral TAVI with 2^nd generation THV. METHODS This retrospective single-center analysis includes 1207 patients, who received transfemoral TAVI with 2^ndgeneration THV between 05/2012-06/2018 and in whom the amount of LVOT calcification was measured quantitatively from contrast-enhanced MSCT. The presence of significant LVOT calcification was defined as >10mm3 calcium. Procedural and clinical outcomes were assessed in accordance with VARC-2 criteria. To compare outcome between patients without (w/o) and with (w) significant LVOT calcification a propensity score matching (PSM) for established outcome predictors was applied. Primary endpoint was defined as the composite of all-cause mortality and stroke/TIA 30 days after the procedure. Secondary endpoints were defined as VARC-2 early safety and clinical efficacy. Median follow-up was 1.10 (1.03, 1.19) years. RESULTS Significant LVOT calcification was present in 37.4% (n=451) of the overall patient cohort. After applying PSM there was no significant difference between patients w/o (n=251) and w (n=251) LVOT calcification with respect to age, gender (all results as follows w/o vs. w LVOT calcification: 82.7 (79.9, 85.8) vs. 82.6 (78.8, 86.3) years, p=0.39; sex (male) 39.4 vs. 41.8%, p=0.65) or relevant comorbidities and estimated surgical risk (STS Score mortality 4.8 ± 2.9 vs. 5.3 ± 3.7%, p=0.13). Patients w LVOT calcification had higher aortic valve calcium volume (composite of annular zone and LVOT, 451.4 (255.7, 772.0) vs. 683.7 (394.9, 1083.8) mm3, p<0.001). In patients w LVOT calcification self-expandable (43.4 vs. 53.4%,p=0.03) and mechanically expandable THV (5.2 vs. 15.5%, p<0.001) were more frequently used, whereas patients w/o were most commonly treated with balloon-expandable THVs (51.4 vs. 31.1%, p<0.001). The rate of VARC2 device success was similar among patients w/o and w LVOT calcification (96.8 vs 94.8%,p=0.37). However, procedural complications like aortic root rupture, valve malpositioning or need for 2^nd THV were numerically more frequent in patients w LVOT calcification. The composite of all-cause mortality and stroke/TIA 30 days after TAVI occurred more frequently in patients w LVOT calcification compared to those w/o (5.7 vs 10.4%, p=0.08), albeit not statistically significant. Moreover, the composite VARC2 “early safety” (13.8 vs. 20.2%,p=0.08) as well as the “clinical efficacy” endpoint (10.4 vs 16.5%, p=0.07) was in favor for patients w/o LVOT calcification, again without statistical significance. According to Kaplan-Meier-Analysis all-cause mortality 1 year after TAVI was higher in patients w vs. w/o LVOT calcification (13.1 vs 20.1%, p=0.08, see fig. 1). CONCLUSIONS Significant LVOT calcification is present in a substantial proportion of patients receiving TAVI and is associated with worse short-term clinical and functional outcomes as well as higher 1-year mortality rates compared to patients w/o LVOT calcification. Effort should be made to further optimize TAVI devices in order to improve outcomes among TAVI patients with LVOT calcification.
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