Deferral of scheduled transcatheter heart valve interventions strongly increases the risk of congestive heart failure

Abstract

Abstract Deferral of non-emergency cardiac interventions is associated with worse clinical outcomes, even post-procedurally. Affected patients show signs of congestive heart failure (CHF) after the waiting time. To identify predictors of CHF with clinical progress during prolonged waiting time, and assess the impact of CHF on the actual intervention date and of the identified baseline predictors in case of deferral on subsequent outcomes. Consecutive patients whose non-emergency cardiac intervention was postponed during the first Covid-19 related lockdown between March 19th and April 30th, 2020 were included (n = 178). Binary logistic regression analysis was performed to identify predictors of clinically progredient CHF, indicated by an NT-proBNP level of > 900 pg/ml on the actual intervention date in combination with worsening of dyspnea as assessed by NYHA class, emergency heart failure hospitalization, or declining left ventricular ejection fraction (LVEF) during the waiting time. Clinical outcomes were compared to a seasonal control group undergoing such interventions in 2019 as scheduled (n = 214). 89 of 178 deferred patients (50.0%) had an NT-proBNP level of > 900 pg/ml in combination with clinical symptoms indicating CHF on the actual intervention date. Thereof, repeated data measurement was available for 72 patients, of whom 54 (75%) experienced new-onset or worsening of CHF, while 18 (25%) had stable, pre-existing CHF. Planned transcatheter heart valve intervention was the only independent predictor of CHF with clinical progress (OR 34.632, 95%-CI 3.337–359.404, p = 0.003). Risk was even higher in patients with planned mitral or tricuspid edge-to-edge-repair (M/T-TEER) than in those with transcatheter aortic valve replacement (TAVR) (82.4% vs. 40.0%; p = 0.035 after Bonferroni correction). During the post-procedural 36-month follow-up, rates of emergency hospitalization or death were significantly higher in patients with CHF and time-to event was shorter compared to those without (57.3% vs. 14.0%, p < 0.001; HR 6.432, 95%-CI 3.476–11.868; log rank p < 0.001). Higher event rates and shorter time-to-event in deferred compared to regularly treated patients after the originally planned intervention date were observed only in those with the predictor scheduled heart valve intervention (83.7% vs. 40.4%, p < 0.001; HR 4.37, 95%-CI 2.50–7.64, log rank p < 0.001). Deferral of planned transcatheter heart valve intervention, TAVR and especially M/T-TEER, leads to a highly increased risk of clinically progredient CHF during prolonged waiting time and worse clinical outcomes. Therefore, these procedures should be prioritized and postponement should be avoided.