Trends Of Myocardial Enzymes And Clinical Correlates And Prognosis Of Myocardial Injury After TAVR

Part 1:Trends of myocardial enzymes after trans-catheter aortic valve replacementObjectives:Myocardial injury is one of the complications of TAVR.The main clinical presentation is the significant increase of myocardial enzymes after TAVR.The objective of this study was to investigate the changes of myocardial enzymes after TAVR for aortic stenosis in Chinese AS population.Methods:Our study retrospectively reviewed the patients who underwent TAVR from 26 August 2014 to 17 August 2017 in the Cardiac Center of the Second Affiliated Hospital of Zhejiang University School of Medicine.After excluding the patients with previous history of surgical valves,apical approach,converted to cardiac surgery during the TAVR procedure,intra-operative death and lack of postoperative examination data,missing cardiac troponin and CK-MB datas after TAVR.The results of levels,timing and frequency of myocardial enzymes were recorded.Results:A total of 289 patients were enrolled in the study.278 patients(96.2%)received myocardial enzymes measurement within 12 hours after the TAVR procedure.218 patients(75.4%),85 patients(29.4%)and 289 patients(72.6%)received myocardial enzymes test within 12 hours to 2 days,2 days to 3 days and 3 days to discharge.The baseline of CK-MB was 13.6 IU/L before the TAVR procedure,20.7 IU/L within 12 hours after the procedure,16.7 IU/L between 12 hours and 2 days after the procedure,13.6 U/L between 2 days and 3 days after the procedure,and 12.0 IU/L between 3 days after the procedure and before discharge.The peak value of CK-MB was 23.3+26.6 IU/L from the procedure to discharge,which was significantly higher than the baseline level before the procedure(P<0.001).Among them,1%(n=3)had a peak value 5 times higher than the upper limit of the normal reference value,0.3%(n=1)had a peak value between 4 and 5 times of the normal reference value,0.3%(n=1)had a peak value between 3 and 4 times of the normal reference value,9%had a peak value between 2 and 3 times of the reference value,21.8%(n=63)had a peak value between 1 and 2 times of the reference value,and 73.4%(n=212)had a peak value after the procedure.The measured peak value did not exceed the upper limit of the normal reference value.During the follow-up period,CK-MB fell below the upper limit of the normal reference value norm and remained stable.There was no statistical difference between CK-MB and preoperative baseline level.The baseline of cTnT was 0.046 ng/mL before the procedure,0.276 ng/mL within 12 hours after the procedure,0.339 ng/mL within 12 hours to 2 days after the procedure,0.396 ng/mL within 2 days to 3 days after the procedure,0324 ng/mL between 3 days after the procedure and before discharge;the peak value of cTnT measured from patients after the procedure to patients during discharge was 0.442(+1.187 IU/L),which was significantly higher than the baseline level before the procedure(P<0.001),with a total of 2.4%(n=7)patients.Postoperative peak values were 100 times higher than the upper limit of normal reference values,4.8%(n=14)between 50 and 100 times higher than the upper limit of normal reference values,17.0%(n=49)between 30 and 50 times higher than the upper limit of normal reference values,15.2%(n=44)between 30 and 50 times higher than the upper limit of normal reference values,and 32.5%(n=94)between the upper limit of normal reference values.The peak value after the procedure was between 1 and 10 times of the normal reference value,and the peak value after the procedure was within the normal reference value range of 0%(n=0).During the follow-up period,cTnT decreased to the reference value range and remained stable.There was no statistical difference between cTnT and baseline level before the procedure.Conclusion:After TAVR procedure,myocardial enzymes of most patients increased in varying degrees,and gradually decreased before discharge,and finally returned to the baseline level and remained stable at the time of follow-up after TAVR.Comparing with CK-MB,cTnT may be a more sensitive marker of myocardial injury after TAVR.Part 2:Clinical correlates and prognosis of myocardial injury after trans-catheter aortic valve replacementObjectives:The objective of this study was to explore the relating factors of post-operative myocardial injury and its impact on prognosis of aortic stenosis in Chinese AS population undergone TAVR procedure.Methods:This study included consecutive patients who were hospitalized in the Second Affiliated Hospital of Zhejiang University School of Medicine from August 26,2014 to November 01,2018 and received TAVR procedure.After excluding the patients who were converted to surgical valve replacement during the procedure,died during the procedure,and had previously undergone surgical valve replacement,according to their results of myocardial enzymes measurements within 72 hours after operation,15 times of the upper limit of normal reference value of cTnT was selected as grouping criteria,according which the patient was divided into myocardial injury group and non-myocardial injury group.The differences of baseline data such as demography,laboratory examination,imaging examination and operation data between the two groups were examined.The endpoints includes death,stroke,hemorrhage,acute kidney injury,new-onset arrhythmia,hospitalization stays and other adverse clinical events were compared between groups.Results:A total of 289 patients were enrolled in the study.The incidence of myocardial injury after TAVR was 51.2%(148 cases).There were no significant differences between the two groups in basic demographic data,preoperative STS surgical risk score and NYHA grades(P>0.050).In terms of personal history,there was no significant difference in smoking history between the two groups(P>0.050).The proportion of patients with Diabetes myocardial injury group was lower(20.3%vs 5.3%,P=0.025).There was no significant difference between the two groups in other clinical history profiles such as peripheral vascular disease,chronic obstructive pulmonary disease,pulmonary hypertension,stroke,history of gastrointestinal bleeding and dialysis?and history PCI procedure(P>0.05).In multivariate analysis,eGFR(OR 0.985,95%CI 0.970-1.000,P=0.050),LVIDs(OR 0.505,95%CI 0.324-0.787,P=0.003)were predictors of post-operative myocardial injury.The patients with myocardial injury has longer ICU stays(1.0 vs 0.6,P=0.050)and longer hospital stay(10.1 vs 8.9,P=0.013).There were no significant differences in stroke,bleeding events,vascular complications,new atrioventricular block,pacemaker implantation and new atrial fibrillation between two groups.There were no significant differences in mortality(2.8%vs 0.8%,P=0.213),incidence of hemorrhagic events,NYHA grades and early safety endpoint between the two groups at 1 month follow-up.Kaplan-Meier curve of 1-year survival analysis showed that the 1-year survival was 94.0%in myocardial injury group and 96.2%in non-myocardial injury group,P=0.425.A total of 172 patients were followed up to 2 years.The 2-year survival rate was 91.5%in the myocardial injury group and 88.2%in the non-myocardial injury group with p=0.509.Conclusion:In terms of short-term prognosis,myocardial injury after TAVR were associated with longer ICU stay and hospitalization stayafter TAVR longer,along side with higher early safety endpoint event percentages.In terms of long-term prognosis,elevated myocardial enzymes after TAVR have limited impact on the Chinese population receiving TF-TAVR.eGFR and LVIDs are independent predictor of myocardial injury in this study.