Background: Patients with severe aortic stenosis at increased surgical risk continue to experience compromised long-term survival despite successful transcatheter aortic valve implantation. We used time-related pathways in a multistate analysis to identify predictors of adverse long-term outcome in patients who underwent transcatheter aortic valve implantation.

Methods and results: In a cohort of 389 patients with a mean age of 82.4 ± 5.8 years and a STS score of 6.8 ± 5.3 undergoing transcatheter aortic valve implantation between 2007 and 2011, multistate analysis was used to estimate mortality and stroke taking into account intercurrent events including kidney injury and the composite of access site and bleeding complications (ABC). Transapical access emerged as a predictor of kidney injury (hazard ratio [HR], 2.12; 95% confidence interval [CI] 1.00-4.47) and ABC (HR, 1.78; 95% CI, 1.07-2.96), but had no impact on the risk of stroke or death. Body mass index ≤20 kg/m(2) increased the risk of stroke or death (HR, 2.64; 95% CI, 1.25-5.54). Age >80 years (HR, 3.15; 95% CI, 1.11-8.92), body mass index ≤20 kg/m(2) (HR, 4.11; 95% CI, 1.33-12.70), prior stroke (HR, 16.42; 95% CI, 3.63-74.21), and presence of atrial fibrillation at baseline (HR, 4.12; 95% CI, 1.87-9.97) increased the risk of stroke and death after an intercurrent event of ABC.

Conclusions: A body mass index ≤20 kg/m(2) was identified as a primary predictor of stroke and death after transcatheter aortic valve implantation during long-term follow-up, whereas transapical access emerged as a predictor of kidney injury and ABC. Age >80 years, body mass index ≤20 kg/m(2), prior stroke, and presence of atrial fibrillation at baseline increased the risk of stroke and death after an intercurrent event of ABC.