Effect of Body Mass Index <20 kg/m2 on Events in Patients Who Underwent Transcatheter Aortic Valve Replacement

doi:10.1016/j.amjcard.2014.10.026

The American Journal of Cardiology

Volume 115, Issue 2, 15 January 2015, Pages 227-233

https://doi.org/10.1016/j.amjcard.2014.10.026 Get rights and content

The Valve Academic Research Consortium-2 has defined body mass index (BMI) <20 as indicative of frailty, which may be one of the co-morbidities not captured by traditional risk factors after transcatheter aortic valve replacement (TAVR). This study aimed to assess the impact of low BMI on clinical outcomes after TAVR. A total of 777 consecutive patients scheduled for TAVR were classified into 3 groups as BMI <20 (n = 56), 20 to 24.9 (n = 322), and ≥25 (n = 399). Procedural complications and clinical outcomes were compared among the 3 groups. They were also analyzed according to propensity-matching model A (BMI <20 [n = 50] vs ≥20 [n = 50]), model B (BMI <20 [n = 50] vs 20 to 24.9 [n = 50]), and model C (BMI <20 [n = 47] vs ≥25 [n = 47]). The differences in baseline characteristics among the 3 groups were adequately adjusted in 3 matched models. Valve Academic Research Consortium-2–defined end points and other complications were similar among the 3 groups in each model. Kaplan-Meier curves indicated no significant differences in cumulative 30-day survival (BMI <20 [91.0%] vs 20 to 24.9 [86.3%], p = 0.33; BMI <20 [91.0%] vs ≥25 [91.4%], p = 0.91, respectively) and 1-year survival (BMI <20 [74.3%] vs 20 to 24.9 [71.8%], p = 0.71; BMI <20 [74.3%] vs ≥25 [77.0%], p = 0.71; respectively). These survival rates were also similar in each of the 3 matched models. In conclusion, BMI <20 was not associated with increased early or midterm mortality. BMI <20 alone may not constitute an additional co-morbidity factor in patients who underwent TAVR.

Section snippets

Methods

A total of 777 consecutive patients with symptomatic severe AS who underwent TAVR were analyzed in 2 French centers (230 in Henri-Mondor University Hospital from December 2007 to May 2012 and 547 at the Institut Cardiovasculaire Paris Sud, Générale de Santé, from October 2006 to May 2012). Of these, 112 and 288 patients in each 2 centers were enrolled from January 2010 to October 2011 as the national FRench Aortic National CoreValve and Edwards 2 (FRANCE-2) registry data.5, 9 Patients were

Results

A number of differences emerged among the 3 BMI groups with respect to age, gender, and prevalence of other baseline patient characteristics including echocardiographic data (Table 1). Consequently, the mean value of logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons Predictive Risk of Mortality was significantly different among the 3 groups. Procedural characteristics and VARC-2–defined and other procedural complications are listed in

Discussion

The main finding of this study is that BMI <20 alone is not associated with increased risks of early and midterm adverse clinical outcomes. Although VARC-2 identifies BMI <20 (and/or body weight loss) as an indicator of frailty predictive of higher risks, a BMI <20 as an isolated factor might not emerge as a predictor of adverse events after TAVR. The revised VARC-2 consensus document suggests novel definitions of additional risk factors not captured by previous VARC criteria and also

Acknowledgment

The authors thank Catherine Dupic for her assistance in the preparation of this report.

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Cited by (24)

Body Mass Index and Outcomes of Transcatheter Aortic Valve Replacement: A Retrospective Observational Study
2023, Current Problems in Cardiology
The influence of body mass index (BMI) on Transcatheter Aortic Valve Replacement (TAVR) outcomes has been the focus of several previous studies. In this study, we examined the relationship between BMI and various clinical outcomes following TAVR procedures. A comprehensive analysis was conducted using a large cohort of patients who underwent TAVR. In this study, we identified patients who underwent Transcatheter aortic valve replacement (TAVR) in the year 2020. Procedure Classification System (ICD-10-PCS) codes were used to identify TAVR cases. The weighted final study sample included 77319 TAVR hospitalizations. Patients were categorized into 5 groups based on their Body Mass Index (BMI. Our findings revealed that there was no significant difference in in-hospital mortality among different BMI groups when compared to patients with a normal BMI (20 to 24.9). patients with a BMI of 25 or higher demonstrated a statistically significant shorter duration of hospitalization compared to those with a normal BMI. patients with a BMI ranging between 30 and 39.9 exhibited decreased hospitalization costs when compared to patients with a normal BMI. Moreover, our study revealed a decrease in atrial fibrillation, acute heart failure and acute kidney injury complications following TAVR in patients with above-normal BMI. Despite similar in-hospital mortality across BMI groups, having a BMI of 25 or greater is associated with improved immediate outcomes following TAVR. These benefits in overweight and obese patients are consistent with findings described in recent literature. Further studies are warranted to explore the underlying mechanisms and potential implications of these associations, as well as to optimize patient selection and management strategies for TAVR procedures.
Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis
2023, Progress in Cardiovascular Diseases
The relationship of body mass index (BMI) and an “obesity paradox” with cardiovascular risk prediction is controversial. This systematic review and meta-analysis aims to compare the associations of different BMI ranges on transcatheter aortic valve implantation (TAVI) outcomes.
International databases, including PubMed, the Web of Science, and the Cochrane Library, were systematically searched for observational and randomized controlled trial studies investigating TAVI outcomes in any of the four BMI categories: underweight, normal weight, overweight, and obese with one of the predefined outcomes. Primary outcomes were in-hospital, 30-day, and long-term all-cause mortality. Random-effects meta-analysis was performed to calculate the odds ratio (OR) or standardized mean differences (SMD) with 95% confidence interval (CI) for each paired comparison between two of the BMI categories.
A total of 38 studies were included in our analysis, investigating 99,829 patients undergoing TAVI. There was a trend toward higher comorbidities such as hypertension, diabetes, and dyslipidemia in overweight patients and individuals with obesity. Compared with normal-weight, patients with obesity had a lower rate of 30-day mortality (OR 0.42, 95% CI 0.25–0.72, p < 0.01), paravalvular aortic regurgitation (OR 0.63, 95% CI 0.44–0.91, p = 0.01), 1-year mortality (OR 0.48, 95% CI 0.24–0.96, p = 0.04), and long-term mortality (OR 0.69, 95% CI 0.51–0.94, p = 0.02). However, acute kidney injury (OR 1.16, 95% CI 1.04–1.30, p = 0.01) and permanent pacemaker implantation (OR 1.25, 95% CI 1.05–1.50, p = 0.01) odds were higher in patients with obesity. Noteworthy, major vascular complications were significantly higher in underweight patients in comparison with normal weight cases (OR 1.62, 95% CI 1.07–2.46, p = 0.02). In terms of left ventricular ejection fraction (LVEF), patients with obesity had higher post-operative LVEF compared to normal-weight individuals (SMD 0.12, 95% CI 0.02–0.22, p = 0.02).
Our results suggest the presence of the “obesity paradox” in TAVI outcomes with higher BMI ranges being associated with lower short- and long-term mortality. BMI can be utilized for risk prediction of patients undergoing TAVI.
Midterm Outcomes of Underweight Patients Undergoing Transcatheter Aortic Valve Implantation: Insight From the LAPLACE-TAVR Registry
2023, JACC: Asia
Obesity is a major risk factor for cardiovascular disease; however, a paradoxical effect of obesity has been reported in patients with heart failure or myocardial infarction. Although several studies have suggested the same obesity paradox in patients undergoing transcatheter aortic valve replacement (TAVR), they included a limited number of underweight patients.
This study aimed to clarify the effect of being underweight on TAVR outcomes.
We retrospectively analyzed 1,693 consecutive patients undergoing TAVR between 2010 and 2020. The patients were categorized according to body mass index: underweight (<18.5 kg/m²; n = 242), normal weight (18.5 to 25 kg/m²; n = 1,055), and overweight (>25 kg/m²; n = 396). We compared midterm outcomes after TAVR among the 3 groups; all clinical events were in accordance with the Valve Academic Research Consortium-2 criteria.
Underweight patients were more likely to be women and have severe heart failure symptoms, peripheral artery disease, anemia, hypoalbuminemia, and pulmonary dysfunction. They also had lower ejection fractions, smaller aortic valve areas, and higher surgical risk scores. Device failure, life-threatening bleeding, major vascular complications, and 30-day mortality occurred more frequently in underweight patients. The midterm survival rate of the underweight group was inferior to those of the other 2 groups (P < 0.0001; average follow-up, 717 days). In the multivariate analysis, underweight was associated with noncardiovascular mortality (HR: 1.78; 95% CI: 1.16-2.75) but not cardiovascular mortality (HR: 1.28; 95% CI: 0.58-1.88) after TAVR.
Underweight patients had a worse midterm prognosis, demonstrating the obesity paradox in this TAVR population. (Outcomes of transcatheter aortic valve implantation in Japanese patients with aortic stenosis: multi-center registry; UMIN000031133)
Relationship of Body Mass Index With Outcomes After Transcatheter Aortic Valve Replacement: Results From the National Cardiovascular Data–STS/ACC TVT Registry
2020, Mayo Clinic Proceedings
Citation Excerpt :
Conversely, overweight patients, and those with mild-moderate (class I and II) obesity, had better 1-year survival than did normal-weight patients undergoing TAVR. Low/normal BMI has been associated with worse long-term survival after SAVR,3 although 2 recent relatively small studies did not find a significant impact of BMI on long-term outcomes following TAVR.5,6 However, in the PARTNER (Placement of Aortic Transcatheter Valves) trial, higher BMI was an independent predictor of better 2-year survival.16
To investigate the relationship of body mass index (BMI) with short- and long-term outcomes after transcatheter aortic valve replacement (TAVR).
The relationship between BMI and baseline characteristics and procedural characteristics was assessed for 31,929 patients who underwent TAVR between November 1, 2011, and March 31, 2015, from the STS/ACC TVT Registry. Registry data on 20,429 patients were linked to the Centers for Medicare and Medicaid Services to assess the association of BMI with 30-day and 1-year mortality using multivariable Cox proportional hazards models. The effect of BMI on mortality was also assessed with BMI as a continuous variable. Restricted cubic regression splines were used to model the effect of BMI and to determine appropriate cut points of BMI.
Among 31,929 patients, 806 (2.5%) were underweight (BMI, <18.5 kg/m²), 10,755 (33.7%) had normal weight (BMI, 18.5- 24.9 kg/m²), 10,691 (33.5%) were overweight (BMI, 25.0-29.9 kg/m²), 5582 (17.5%) had class I obesity (BMI, 30.0-34.9 kg/m²), 2363 (7.4%) had class II obesity (BMI, 35.0-39.9 kg/m²), and 1732 (5.4%) had class III obesity (BMI, ≥40 kg/m²). Patients in various BMI categories were different in most baseline and procedural characteristics. On multivariable analysis, compared with normal-weight patients, underweight patients had higher mortality at 30 days and at 1 year after TAVR (hazard ratio [HR], 1.35; 95% CI, 1.02-1.78 and HR, 1.41; 95% CI, 1.17-1.69, respectively), whereas overweight patients and those with class I and II obesity had a decreased risk of mortality at 1 year (HR, 0.88; 95% CI, 0.81-0.95, HR, 0.80; 95% CI, 0.72-0.89, and HR, 0.84; 95% CI, 0.72-0.98, respectively). For BMI of 30 kg/m² or less, each 1-kg/m² increase was associated with a 2% and 4% decrease in the risk of 30-day and 1-year mortality, respectively; for BMI greater than 30 kg/m², a 1-kg/m² increase was associated with a 3% increased risk of 30-day mortality but not with 1-year mortality.
Results of this large registry study evaluating the relationship of BMI and outcomes after TAVR support the existence of an obesity paradox among patients with severe aortic stenosis undergoing TAVR.
Prognostic value of objective nutritional status after transcatheter aortic valve replacement
2019, Journal of Cardiology
Citation Excerpt :
Baseline characteristics are shown in Table 1. Mean body mass index (BMI) (kg/m2) was lower in the high CONUT group than in the low CONUT group (20.3 ± 2.4 vs. 22.8 ± 3.5, p < 0.001), but the percentage of patients whose BMI was <20 was similar between the two groups (20% vs. 10%, p = 0.15) [20]. The prevalence of atrial fibrillation and CFS was higher in the high CONUT group than in the low CONUT group (43% vs. 23%, p = 0.03) [median (IQR), 4.5 (3.75–6) vs. 4 (3–5), p < 0.001].
This study aimed to elucidate the prognostic value of objective nutritional status after transcatheter aortic valve replacement (TAVR).
This study enrolled 150 consecutive patients who underwent TAVR between February 2014 and March 2017. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score before TAVR. Patients were divided into a high CONUT score (malnutrition status >4 points, n = 30) or low CONUT score (normal nutritional status 1–4 points, n = 120) group. The primary endpoint was mortality within 1-year post-TAVR.
Patients in the high CONUT group were characterized by low body mass index (kg/m²) (20.3 ± 2.4 vs. 22.8 ± 3.5, p < 0.001), a higher prevalence of atrial fibrillation (43% vs. 23%, p = 0.03), and more common frailty [median (interquartile range) Clinical Frailty Scale (CFS) score, 4.5 (3.75–6) vs. 4 (3–5), p < 0.001]. Mortality rate within 1-year post-TAVR was significantly higher in the high CONUT group (43.6% vs. 6.7%, p < 0.001). High CONUT score was independently associated with poor prognosis post-TAVR [adjusted hazard ratio, 8.20; 95% confidence interval (CI), 3.10–22.6; p < 0.001]. On integrated discrimination improvement (IDI) analysis, malnutrition status improved CFS for predicting mortality post-TAVR (IDI, 0.15; 95% CI, 0.07–0.23; p < 0.001).
Objective malnutrition status was predictive of mortality post-TAVR and provided complementary prognostic information to the CFS. Thus, objective nutritional status may refine the clinical risk stratification of patients who undergo TAVR.
Relation of Body Mass Index to Risk of Death or Stroke in Patients Who Underwent Transcatheter Aortic Valve Implantation
2019, American Journal of Cardiology
Obesity and overweight have been associated with better clinical outcomes in different populations with a diverse spectrum of cardiovascular disease (obesity paradox). However, conflicting data exist about the relation between body mass index (BMI) and outcomes after transcatheter aortic valve implantation (TAVI). The aim of this study is to evaluate the association of body mass index with clinical outcomes in patients with severe aortic stenosis (AS) who underwent TAVI. The study cohort included 379 consecutive patients with symptomatic severe AS who underwent TAVI between March 2010 and February 2017 in 3 centers in East Asia. Patients were grouped into tertiles of baseline BMI (first tertile: ≤22.3 kg/m², second tertile: 22.4 to 24.8 kg/m², and third tertile: ≥24.9 kg/m²). The primary outcome was a composite of death from any causes or stroke at 1 year. The median (interquartile range) BMI was 23.5 (21.8 to 26.1) kg/m². During the median follow-up of 18.4 months, there were 69 deaths and 23 strokes. At 1 year, the primary outcome occurred in 21.9% in the first tertile, 18.7% in the second tertile, and 7.8% in the third tertile, respectively (p = 0.009). After adjustment for confounding variables, an inverse relation was observed between BMI and primary outcome: with the third BMI tertile as the reference category, the adjusted hazard ratios were 2.51 (95% confidence interval, 1.20 to 5.26) for the second BMI tertile and 2.61 (95% confidence interval, 1.20 to 5.66) for the first BMI tertile. In conclusion, in patients with severe AS who underwent TAVI, an inverse association between BMI and the risk of death or stroke was observed.

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Valvular Heart DiseaseEffect of Body Mass Index <20 kg/m2 on Events in Patients Who Underwent Transcatheter Aortic Valve Replacement

Section snippets

Methods

Results

Discussion

Acknowledgment

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

JACC Cardiovasc Interv

JACC Cardiovasc Interv

JACC Cardiovasc Interv

J Am Coll Cardiol

Am J Cardiol

JACC Cardiovasc Interv

Am J Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

Valvular Heart Disease
Effect of Body Mass Index <20 kg/m² on Events in Patients Who Underwent Transcatheter Aortic Valve Replacement