Long-term outcome after TAVI: The valve is cured but the vessels remain harmful!

Background Some patients still exhibit a premature poor outcome after transcatheter aortic-valve implantation (TAVI). Factors leading to this poor outcome should be identified. Objective To assess the evolution overtime of the prognostic impact of 3 categories of predictors: 1) age and comorbidities, 2) vascular and 3) cardiac factors. Patients and methods Ancillary study from the C4CAPRI study including consecutive patients referred for TAVI to four high-volume French centers. The primary and secondary outcomes were cardiovascular and all-cause mortality, respectively. Cox models included for each category respectively: 1) age, sex, renal function, and pulmonary disease; 2) NYHA, ejection fraction, pulmonary pressures, preoperative aortic gradient and mitral regurgitation; 3) coronary artery disease, peripheral vascular disease, previous stroke and thoracic aorta calcification (TAC) assessed by CT-scan. Evolution of the effect of predictive factors overtime was determined by the distribution of scaled Schoenfeld residuals against time. Results A total of 1425 patients were included between 2010 and 2014. After 1000 days of follow-up, 364 (26%) deaths occurred of whom 241 (17%) of cardiovascular cause. Significant predictors of mortality were 1) age, renal function, pulmonary disease (for all-cause death only); 2) NYHA, pulmonary pressure, aortic gradient; 3) TAC, peripheral vascular disease (for all-cause death only). The factors which effect overtime was stable or increased were mainly vascular factors at variance with cardiac factors which effect vanished during the follow-up. The effect of comorbidities was in-between. Conclusion TAVI solves most of the cardiac problem as indicated by the decreased deleterious effect of cardiac factors overtime. On the contrary, the pejorative value of vascular factors persists or increases advocating for their involvement in the course of the disease. Future therapy should target the vascular tree to improve outcome after TAVI.