VARC-3 Criteria : Adding Prognosis to Injury

How to best define periprocedural myocardial infarction (PPMI) in the setting of transcatheter aortic valve replacement (TAVR) remains challenging. PPMI is inevitable with transapical TAVR as a result of direct myocardial mechanical trauma. It is the mainstay with other vascular approaches consequent to hypotension, valve delivery mechanical trauma, calcific embolization, acute bleedings, or valvular prosthetic coronary artery obstruction, occurring in frail patients commonly burdened with underlying coronary artery disease. The Valve Academic Research Consortium (VARC) was precisely initiated to provide standardized consensus definitions, paving the way for randomized controlled trials and observational studies ever since. Back in 2011, the VARC-1 defined PPMI as an acute ischemic event associated with documented and clinically significant myocardial necrosis occurring within 72 hours of the procedure. Cardiac necrosis was defined by the continuous elevation of cardiac biomarkers on consecutive samples, preferably creatinine kinase-myocardial band (CK-MB). In 2012, the VARC criteria were updated, and PPMI characterization was simplified, with only 1 postprocedural abnormal sample required, whereas the threshold values were adjusted to account for the different use of CK-MB or cardiac troponin (cTn). Interestingly enough, this updated definition of PPMI was not consistently associated with adverse outcomes after TAVR, suggesting that different thresholds could be considered.

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