Transcatheter Aortic Valve Replacement in Moderate-risk Aortic Stenosis Patients

Q: What is the clinical evidence from this study?

Study design: Review. Population: Moderate-risk aortic stenosis. Intervention: Transcatheter aortic valve replacement (TAVR) vs. Open surgical aortic valve replacement (AVR).

Q: What does this research mean for the field?

Transcatheter aortic valve replacement in moderate-risk patients should be approached with caution until long-term valve durability, stroke risk, and institutional surgical outcomes are clarified. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Lars Georg Svensson

doi:10.15420/icr.2011.9.1.41

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January 1, 2011Interventional Cardiology Reviews Research ResourcesOpen Access

Transcatheter Aortic Valve Replacement in Moderate-risk Aortic Stenosis Patients

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Key result

TAVR warrants caution in moderate-risk patients pending long-term durability and stroke data.

Why the study?

The role of transcatheter aortic valve replacement in intermediate-risk patients involves unresolved questions regarding institutional and surgeon results, physician and hospital alignments, and payment.

Does transcatheter aortic valve replacement (TAVR) improve clinical outcomes compared to open surgical aortic valve replacement (AVR) in moderate-risk aortic stenosis patients?

Key Points

To evaluate key considerations regarding the expansion of transcatheter aortic valve replacement into moderate-risk patients with severe aortic stenosis.
Expert commentary synthesizing institutional surgical outcomes, registry findings, and clinical trial evidence from the PARTNER trial.
Analysis of single-center surgical aortic valve replacement and transcatheter outcomes benchmarked against Society of Thoracic Surgeons predicted risk scores.
In the TVT/NCDR registry of the first 7,710 commercial patients, the mean STS score was 7, indicating that moderate-risk patients were already undergoing transcatheter procedures.
Institutional single-center isolated surgical aortic valve replacement demonstrated observed mortality rates of 0.60% in 2011 (n=479) and 0.40% in 2012 (n=539), markedly lower than STS predicted scores of 3.48% and 3.96%.
Among 257 transfemoral transcatheter procedures, outcomes included 11 conversions (4.2%), one death (0.4%), and two strokes (0.8%).

Structured PICO

Does transcatheter aortic valve replacement (TAVR) improve clinical outcomes compared to open surgical aortic valve replacement (AVR) in moderate-risk aortic stenosis patients?

P

Population

Moderate-risk and intermediate-risk patients with severe aortic stenosis being evaluated for transcatheter versus open surgical aortic valve replacement.

I

Intervention

Transcatheter aortic valve replacement (TAVR), including transfemoral (TF) and transapical (TA) approaches

C

Comparator

Open surgical aortic valve replacement (AVR)

This review highlights that expanding TAVR to moderate-risk aortic stenosis patients requires careful consideration of institutional surgical AVR excellence, unresolved questions regarding valve durability and stroke risk, physician-hospital financial alignments, and societal healthcare reimbursement constraints.

Limitations

Long-term data are not available for valve durability, particularly in younger patients with longer expected survival
Attempts at finding a reliable ROC predictive score for TAVR have not been effective (c-statistic <0.6)
Unanswered questions remain regarding stroke risks and the long-term effect of perivalvular leaks
Long-term data are not available for valve durability, particularly in younger patients with longer expected survival.
Reliable predictive risk models for TAVR are lacking (ROC c-statistic <0.6).
Long-term effects of perivalvular leaks and stroke risks in younger intermediate-risk patients remain unanswered.

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Implication

Caution advised before expanding TAVR to moderate-risk patients; leaves open durability, stroke, and center-specific surgical outcome questions.

Abstract

The Placement of Aortic Transcatheter Valves (PARTNER) trial showed the effectiveness of transcatheter aortic valve replacement (TAVR) for inoperable patients and non-inferiority for mortality versus open valve replacement. There are three questions concerning the role of TAVR for intermediate-risk patients. These relate to: institutional and surgeon results, physician and hospital alignments, and who will pay.

Discussion

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Cite This Study

Lars Georg Svensson (2011) conducted a review in Moderate-risk aortic stenosis. Transcatheter aortic valve replacement (TAVR) vs. Open surgical aortic valve replacement (AVR) was evaluated.

synapsesocial.com/papers/6aeee210c16ea90f1532cec9 https://doi.org/10.15420/icr.2011.9.1.41

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Transcatheter Aortic Valve Replacement in Moderate-risk Aortic Stenosis Patients

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Transcatheter Aortic Valve Replacement in Moderate-risk Aortic Stenosis Patients

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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