The impact of mitigating perioperative inflammation on risk of conduction disturbances after transcatheter aortic valve implantation; is it time to coat the valve?
K Abdelsayed, A M Amin, M C Downey, A Almahdy, M T Desouki, D Witt, E Zishiri, J SenguptaAbstract
Introduction
Postoperative conduction disturbances, partially mediated by procedural inflammation and edema, represent a significant challenge after transcatheter aortic valve implantation (TAVI). They are associated with higher morbidity and mortality, especially in patients at high risk of conduction disturbances. It is unclear whether mitigating the local inflammation around the valve perioperatively can reduce the risk of these complications.
Objective
We aim to explore any protective real-world association for preoperative systemic steroids with post-TAVI conduction disturbances.
Methods
Using the TriNetX US Collaborative Network, we recruited patients >18 years with a diagnosis of chronic systemic inflammatory, infiltrative, ischemic, or structural heart diseases referred to their first TAVI (January 2014-June 2024). The cohort was divided into those who received new systemic steroids for any indication within one week pre-TAVI and those who did not receive steroids before or up to 6 months postoperative. Patients with previous conduction disturbances, surgical cardiac valve procedures, an implanted pacemaker or defibrillator, or prior systemic steroids use before the first week were excluded. Propensity score matching (PSM) was applied based on 62 clinically relevant comorbidities. A survival analysis was applied using the Log-Rank test and a univariate Cox regression to compare the hazards of new-onset conduction disturbances within 30 days post-TAVI. An E-value sensitivity analysis examined the impact of unmeasured confounders on outcomes. A multivariate Cox regression was performed before PSM to identify predictors of conduction disturbances among the whole cohort.
Results
The control group included 13,797 patients, while the steroids group included 2,321, representing 71 USA healthcare organizations. After PSM, each group included 2,301 well-matched patients; mean age was 77.0 ± 9.2 and 76.7 ± 9.2 years while 55.8% and 56.7% were males, respectively (Table 1). Glucocorticoids were associated with a statistically significant reduction of need for permanent pacemakers (PPM) within 30 days post-TAVI (HR= 0.678, 95% CI [0.526; 0.873], p=0.002, E-value = 2.31) (Figure-1). Likewise, all other conduction disturbance outcomes were significantly lower with glucocorticoids (P<0.03) (Figure-1). The multivariate models confirmed steroids to be independent predictors of reduced conduction disturbances in the whole cohort.
Conclusion
Preoperative systemic steroids were independently associated with significantly lower PPM and new conduction disturbances after TAVI in patients at high-risk of conduction disturbances. These findings reinforce the role of inflammation in post-TAVI conduction injuries. If this role is confirmed in future studies, supplying the valve with a localized anti-inflammatory or drug-eluting technology could be a valuable idea to reduce those complications while minimizing systemic drug-related side effects.