Prognostically Significant Myocardial Injury in Patients Undergoing Transcatheter Aortic Valve Replacement

Abstract

Background: Troponin elevation occurs commonly in the setting of transcatheter aortic valve replacement (TAVR). There is a lack of information on the extent of troponin elevation post TAVR that is prognostically significant. We assessed the optimal cutoff for post-TAVR troponin T elevation that correlates with long-term mortality. We also examined the relationship between coronary artery disease (CAD) and prognostically significant myocardial injury in TAVR. Methods and Results: This is a retrospective, observational single-center study involving patients who underwent TAVR at Cleveland Clinic between 2010 and 2015. Five hundred ten patients were included (mean follow-up of 2.6±1.3 years). Receiver operating characteristic analysis showed that troponin T elevation ≥3× upper limit of normal was the best predictor of long-term mortality post TAVR with area under the curve of 0.57, with transapical TAVR patients excluded. Multivariate analyses confirmed that troponin T elevation ≥3× upper limit of normal was significantly associated with increased long-term mortality post TAVR (hazard ratio 1.57, CI 1.04–2.38, P=0.03). The most common causes for the presence of unrevascularized CAD included the presence of chronic total occlusion in the native/graft vessels (49.7%) and diffuse/complex CAD unsuitable for PCI (24.6%). The presence of unrevascularized CAD and significant left main disease correlated with increased mortality, but not with the presence of prognostically significant myocardial injury. Conclusions: Troponin T elevation of ≥3× upper limit of normal is associated with increased long-term mortality after TAVR, except for the transapical approach. This prognostically significant myocardial injury does not appear to be secondary to severe CAD/unrevascularized CAD or left main disease, but rather is associated with other factors such as post-TAVR complications.