Identifying Patients Who Do Not Benefit From Transcatheter Aortic Valve Replacement

> In this world, there are only two tragedies. One is not getting what one wants, and the other is getting it. > > —Oscar Wilde (1854–1900)Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of patients with severe and symptomatic aortic stenosis. Patients at extreme risk for open surgery (inoperable) have an absolute benefit in 1-year survival that exceeds 20%,1,2 and high-risk patients have outcomes that are noninferior to surgery for 2 years.3 Nonetheless, the 1- and 3-year mortality in extreme-risk patients who undergo TAVR is ≈30% and 50%, respectively.1 These patients did not derive the anticipated survival benefit from TAVR, and it would be beneficial to be able to predict this adverse outcome preprocedure.Article see p 240 In this regard, several investigations have identified factors that are associated with poor outcome after TAVR.4–12 These include noncardiac factors associated with mortality, as well as cardiac diseases and procedural complications (Table). Analyses of individual predictive factors are helpful in risk stratifying patients but have the weakness that they offer little practical help in the complex decision making of whether to offer TAVR to individual high-risk patients.View this table:Table. Factors Associated With Poor Outcome After Transcatheter Aortic Valve ReplacementFor example, in the recently reported Italian multicenter registry of >1000 patients receiving TAVR with the CoreValve device, patients with moderate or severe mitral regurgitation (MR) had an ≈2-fold higher mortality at both 30 days and 1 year than those without significant MR.12 Modest improvement in …