title: Mortality Predictors in Patients Referred for but Not Undergoing Transcatheter Aortic Valve Replacement.
abstract: Although transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with aortic stenosis (AS) who are candidates for valve replacement, some patients remain untreated, and their outcomes are not clear. We evaluated 172 consecutive patients with severe symptomatic AS referred for TAVR who declined (n = 55) or were not candidates for (n = 117) intervention. We examined clinical and echocardiographic variables associated with mortality. There were 77 deaths, and mean follow-up was 17.9 ± 10.9 months for survivors. Mortality rate at 1 and 2 years was 39.2% and 52.6%, respectively. There was a significant difference in mortality rate between patients who declined the procedure and those who were not candidates (p = 0.001), with 1-year mortality rates of 20.6% and 48.4%, respectively. On multivariate analysis, 4 variables were independently associated with all-cause mortality: New York Heart Association Class IV heart failure (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.6 to 4.2, p <0.001), glomerular filtration rate <48 ml/min (HR 2.1, 95% CI 1.3 to 3.4, p = 0.002), albumin <3.9 g/dl (HR 1.9, 95% CI 1.2 to 3.1, p = 0.007), and ejection fraction <50% (HR 1.9, 95% CI 1.4 to 3.0, p = 0.01). In this new era with expanded treatment options, patients with severe symptomatic AS who remain untreated after referral for TAVR experience a mortality rate of 39% at 1 year. The presence of advanced heart failure, renal dysfunction, low albumin, and/or left ventricular dysfunction identifies patients at higher risk of mortality.
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: Donna
authors.initials: D
authors.lastname: Kang
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: David S
authors.initials: DS
authors.lastname: Bach
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: Stanley
authors.initials: S
authors.lastname: Chetcuti
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Michigan.
authors.forename: George Michael
authors.initials: GM
authors.lastname: Deeb
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: Paul M
authors.initials: PM
authors.lastname: Grossman
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Michigan.
authors.forename: Himanshu J
authors.initials: HJ
authors.lastname: Patel
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: Daniel
authors.initials: D
authors.lastname: Menees
authors.affiliation: Department of Surgery, University of Michigan, Ann Arbor, Michigan.
authors.forename: Matthew
authors.initials: M
authors.lastname: Romano
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address: labt@med.umich.edu.
authors.forename: Troy M
authors.initials: TM
authors.lastname: LaBounty
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality* / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D005919:Glomerular Filtration Rate; D006333:Heart Failure / Q000453:epidemiology* / Q000503:physiopathology; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D018579:Patient Selection; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors; D012709:Serum Albumin; D012720:Severity of Illness Index; D013318:Stroke Volume; D065467:Transcatheter Aortic Valve Replacement; D016312:Treatment Refusal; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology* / Q000503:physiopathology
chemical_list: D012709:Serum Albumin