By Michael Crawford, MD, Editor
SYNOPSIS: A 12-year experience with transcatheter aortic valve replacement at one Paris hospital demonstrated chronic systemic corticosteroid use increases the incidence of major 30-day complications and all-cause mortality at one year.
SOURCE: Gautier A, Urena M, Chong-Nguyen C, et al. Outcomes of transcatheter aortic valve implantation in patients receiving chronic systemic corticosteroid treatment. Am J Cardiol 2020;130:108-114.
Chronic systemic corticosteroid therapy (SCT) can lead to cutaneous and vascular fragility as well as delayed wound healing. It is known to increase the risk of percutaneous coronary intervention complications, but little is known about the effect on outcomes with transcatheter aortic valve replacement (TAVR).
Gautier et al interrogated Paris’ Bichat-Claude Bernard Hospital TAVR database for chronic SCT from late 2006 through 2018. Chronic SCT was defined as use for at least 30 days before the procedure. The authors compared these patients to TAVR patients not taking steroids. Researchers followed both groups through outpatient visits or phone calls at 30 days and 12 months after TAVR.
The primary endpoints were 30-day vascular and bleeding complications, permanent pacemaker implantation, acute kidney injury, stroke, cardiac tamponade, and one-year all-cause mortality. Among 1,299 patients who underwent TAVR, 48 were on chronic SCT. The mean age of the entire population was 81 years. The major difference in baseline criteria between the two groups was hemodialysis in 12% of the SCT patients and 3% of the controls (P = 0.002). Procedural outcomes were not different between the two groups.
At 30 days, the steroid group had experienced more major vascular complications (17% vs. 7%; P = 0.02), more major bleeds (23% vs. 12%; P = 0.04), and cardiac tamponade caused by left ventricular puncture or rupture (8% vs. 2%; P = 0.03). At one-year follow up, 37% of the SCT group had died vs. 12% of the control group (P < 0.0001). Of note, a cardiovascular death was more common in the non-SCT group (78% vs. 55%; P = 0.047), and a non-cardiovascular death was more common in the SCT group (44% vs. 22%). The authors concluded chronic SCT use in patients undergoing TAVR increases the incidence of vascular complications, life-threatening bleeding, and cardiac tamponade at 30 days and all-cause mortality at one-year follow-up.
This was a relatively small observational study from one center in France exploring the effect of chronic SCT therapy (> 30 days) on major TAVR complications at 30 days and all-cause mortality at one year. Not surprisingly, both were significantly higher with robust hazard ratios (HR) by multivariate analysis of > 2.0: major vascular complications (HR = 2.52), major bleeds (HR = 2.02), cardiac tamponade (HR = 4.05), and one-year mortality (HR = 2.29). Presumably, these complications were caused by the vascular and tissue fragility induced by chronic SCT. The latter is supported by the cases of cardiac tamponade caused by left ventricular puncture and annular rupture. The multivariate analysis of the patients’ comorbidities showed chronic SCT was the only predictor of all-cause mortality with a HR > 2. This analysis did not list the reasons for SCT therapy, which included vasculitis in 14 patients, kidney or liver transplant in 10, chronic arthritis in eight, and other autoimmune disease in 11. Considering 44% of patients on chronic SCT died from non-cardiac reasons at one year, the importance of non-cardiac disease in the outcome of TAVR is clear.
One-year survival in the entire population was 86%, which is similar to that reported from other databases. Other studies of SCT in TAVR patients have shown lower complication rates, but these studies included patients on inhaled steroids for chronic lung disease, which has been shown to lead to few complications. Gautier et al excluded such patients from their study. Unfortunately, this study was too small to stratify the patients by steroid dose or the underlying indication. There was a trend toward less pacemaker use in the SCT group (17% vs. 23%). One potential cause of heart block after TAVR is mechanical compression damage to the conduction system, resulting in acute inflammation. It has been observed that patients given corticosteroids periprocedurally for angiographic dye allergy are less likely to need pacemakers. These observations will need to be tested in larger populations before any recommendations for this therapy in TAVR can be made.
This study, although hypothesis-generating because of its observational nature, suggests chronic SCT should be added to the list of comorbidities to consider when deciding whether TAVR is likely to be futile because of a high incidence of mortality in one year, mainly because of the underlying diseases treated. This study’s results were not strong enough to lead cardiologists to use SCT as a yes or no criterion for TAVR, but certainly should occasion a consideration of the prognosis of the underlying disease treated.