Meta-Analysis of the Prognostic Value of Psoas-Muscle Area on Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation

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We performed a meta-analysis of currently available studies assessing prognostic value of psoas-muscle area (PMA) on mortality in patients who underwent transcatheter aortic valve implantation (TAVI). MEDLINE and EMBASE were searched through May 2018 to identify studies reporting ≥1-year all-cause mortality in PMA-stratified TAVI patients. A hazard ratio of follow-up (including early) mortality for “lowest-quantile” versus “higher-quantiles” PMA. Study-specific estimates were combined in the random-effects model. Our search identified 6 eligible studies enrolling a total of 1,237 TAVI patients with 1-year to 2-year (midterm) follow-up. A primary meta-analysis pooling all hazard ratios for “lowest-quantile versus higher-quantiles” PMA demonstrated significantly higher mortality in “lowest-quantile” than “higher-quantiles” patients (p <0.0001). A subgroup meta-analysis indicated no significant difference in mortality between “<50th- and ≥50th-percentile” patients (p = 0.95), but significantly higher mortality in “lowest-tertile” than “higher-tertiles” patients (p = 0.0009) and in “lowest-quartile” than “higher- quartiles” patients (p = 0.0003). A secondary meta-analysis revealed significantly higher mortality in “lowest-tertile” than “mid-tertile” patients (p = 0.01) and in “lowest-tertile” than “highest-tertile” patients (p = 0.01). A gender-stratified meta-analysis showed significantly higher mortality in “lowest-quantile” than “higher-quantiles” patients in both men (p = 0.0008) and women (p = 0.01). In conclusion, low PMA, especially “lowest-tertile/quartile” PMA, is a predictor of high all-cause mortality at midterm follow-up after TAVI for both men and women. However, PMA categorization into 50th percentiles may be invalid to predict mortality.

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Methods

All studies investigating prognostic value of PMA on mortality after TAVI for severe AS were identified using a 2-level search strategy. First, databases including MEDLINE and EMBASE were searched through May 2018 using Web-based search engines (PubMed, OVID). Search terms included psoas and aortic valve. Second, relevant studies were identified through a manual search of secondary sources including references of initially identified studies and a search of reviews and commentaries. All

Results

Of 31 potentially relevant studies screened initially, 6 eligible studies12, 13, 14, 15, 16, 17 enrolling a total of 1,237 TAVI patients with 1-year to 2-year (considered to be “midterm”) follow-up were identified and included (Table 3). According to PMA, 4 studies14, 15, 16, 17 divided patients into tertiles, one13 into 50th-percentiles, and one12 into quartiles. Mean age (78.96 to 83.3 years), body mass index (26.3 to 29.58 kg/m2), and Society of Thoracic Surgeons predicted risk of mortality

Discussion

The results of the present study suggest that low PMA, especially “lowest-tertile/quartile” PMA, is a predictor of high all-cause mortality at midterm (1-year to 2-year) follow-up after TAVI for patients (both men and women) with severe AS. However, PMA categorization into 50th percentiles may be invalid to predict mortality.

Low PMA as a continuous variable, not as a categorical variable (quantiles), may not be associated with high mortality at midterm follow-up after TAVI. In the study by Garg

Disclosures

The authors have no conflicts of interest to disclose.

References (31)

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    Although psoas muscle quantity and quality have been shown to be associated with outcomes in surgical and trauma patients, the applicability of these metrics in TAVR patients is unclear.24-27 A meta-analysis, including six papers and sample size of 1,237 by Takagi et al., demonstrated that small psoas muscle cross-sectional area was associated with increased all-cause mortality at one-to-two years after TAVR.11 PD was not investigated.

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    In TAVI patients, low psoas CSA has been found to correlate with early poor outcomes and high resource utilisation [9,10], with 6-month mortality [11], 12-month mortality [12], and, in women, with longer-term mortality [13,14]. Recent meta-analysis data has also suggested that patients in the lowest tertile/quartile of psoas CSA are at increased risk of mid-term mortality [15]. Available retrospective studies investigating psoas CSA as a predictor of mortality in TAVI patients have been of relatively small sample size with the inherent limitation of confounding due to unmeasured baseline variables.

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    Garg et al. reported that low PMA could predict poor early outcome and higher resource utilization after TAVI, but did not predict 1-year mortality (28). A meta-analysis of the prognostic value of PMA on mortality after TAVI concluded that although the lowest tertile/quartile PMA may be a predictor of higher all-cause mortality at midterm follow-up after TAVI, PMA categorization into 50th percentiles or PMA as a continuous variable was unable to predict post-TAVI mortality (38). In a recent larger study including 1076 patients reported by Kofler et al., the lowest tertile PMA was shown to be independently associated with 30-day and mid-term mortality, but the association between PMA and LOS was not mentioned (39).

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