Author + information
- Sadeer Al-Kindi1,
- Guilherme F. Attizzani2,
- Ahmad Alkhalil3,
- Sahil Parikh4,
- Daniel Simon5,
- Marco Costa6 and
- David Zidar7
- 1University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
- 2University Hospital Harrington Heart & Vascular Institute, Cleveland, Ohio, United States
- 3Rutgers University Hospitals, Newark, New Jersey, United States
- 4Columbia University Medical Center, NY, New York, United States
- 5University Hospitals Case Medical Center, Cleveland, Ohio, United States
- 6University Hospitals Coimbra, Coimbra, Portugal
- 7Harrington Heart & Vascular Institute, Cleveland, Ohio, United States
Traditional surgical risk scores only modestly predict outcomes after transcatheter aortic valve replacement (TAVR), an important impediment to the design of personalized interventions to improve intermediate and long term outcomes. We sought to determine whether levels of individual leukocyte subsets (neutrophils, monocytes, and lymphocytes) and their post TAVR trajectory are related to survival after TAVR.
We conducted a retrospective study of 136 consecutive patients undergoing transfemoral TAVR. White blood cell subsets before and 1 day after TAVR were analyzed using Cox-proportional hazards regression and Kaplan Meier analyses.
TAVR was associated with a modest increase in total leukocyte counts (median difference 1.6 x 109/L, P<0.001) which was driven by increases in neutrophils (median difference 1.9 x109/L, P<0.001), and monocytes (median difference 0.16 x109/L (P<0.001). In contrast, absolute lymphocyte counts (ALC) decreased sharply after TAVR (median difference -0.43 x109/L, P<0.001). Baseline neutrophil and monocyte counts were not associated with long term survival whereas a higher ALC before TAVR was strongly associated with improved survival independent of age, gender, or Society of Thoracic Surgeons (STS) clinical risk score (STS- adjusted HR: 0.40 [0.21-0.77] per 10ˆ9/L, P=0.006). 2-year survival according baseline ALC tertiles was 87%, 68%, and 46% respectively. 35% of patients had lymphopenia (ALC < 1.2 x 10ˆ9/L) prior to TAVR and these patients did not differ from those without lymphopenia with regard to clinical variables including age, gender, ethnicity, kidney disease, malignancy, or STS score. However, they had substantially reduced survival regardless of STS score (figure 1B) and even when the procedure was accompanied by minimal peri-procedural injury as measured by post TAVR leukocytosis (figure 1D). In contrast, post TAVR survival in patients without lymphopenia was highly dependent on both STS score (figure 1A) and peri-procedural injury (figure 1C).
Patients with diminished lymphocyte counts prior to TAVR may represent a previously unappreciated high risk population with limited long term survival after TAVR. Additional study is needed to determine the role of baseline immune status in patients referred for TAVR, and whether the risk associated with lymphopenia is modifiable.
STRUCTURAL: Valvular Disease: Aortic