Age key to transcatheter versus surgical aortic valve replacement choice
medwireNews: Researchers report that patients with severe aortic stenosis who have a shorter life expectancy or place a low value on the risk of long-term valve degeneration may have more to gain from transfemoral transcatheter aortic valve implantation (TAVI) than surgical replacement.
They analysed data from four randomised trials involving 3179 patients, most of whom were older than 80 years of age and at low to intermediate perioperative risk of death. Over a median follow-up of 2 years, transfemoral TAVI was associated with better outcomes than surgical aortic valve replacement (SAVR) in terms of mortality, stroke, acute kidney injury and bleeding.
Among the 1578 patients undergoing TAVI there were an estimated 30 fewer deaths per 1000 patients than among the 1550 undergoing SAVR, while for stroke, acute kidney injury and bleeding, there were 20, 53, and 252 fewer instances, respectively. The occurrence of new-onset atrial fibrillation was also reduced, with 178 fewer instances, and the duration of index admission was 3–4 days shorter.
“These benefits, however, came with associated harms”, the team points out in The BMJ.
TAVI was associated with 18 more instances per 1000 patients of moderate to severe symptoms of heart failure than SAVR, the permanent insertion of 134 more pacemakers per 1000 patients and seven more aortic valve reinterventions over the short term.
“[W]e have clarified the trade-offs between TAVI and SAVR and identified issues of residual uncertainty”, say Reed Siemieniuk (McMaster University, Hamilton, Ontario, Canada) and co-researchers.
Based on these, they believe that the benefits of transfemoral TAVI over SAVR and the fact that it is less invasive are likely to make it more compelling for older patients, such as those aged over 85 years, and potentially for those aged 65–85 years, whereas younger patients, “for whom valve longevity could be extremely important”, may be more likely to choose SAVR.
They note, however, that success with TAVI depended on the approach. Most of the patients underwent percutaneous TAVI with transfemoral access, but 209 (77.1%) of patients undergoing non-percutaneous TAVI had transapical access.
This latter approach shared the same benefits as transfemoral TAVI in terms of less bleeding, less atrial fibrillation and shorter hospital stay, but increased the risk of stroke, compared with SAVR, with a difference of 45 cases per 1000 patients, and possibly mortality, with a difference of 57.
The researchers comment that as a result “patients in whom a transfemoral TAVI approach is not feasible are unlikely to view the transapical approach […] as an attractive option.”
The data were extracted by two independent reviewers who assessed the trials for eligibility, risk of bias and data abstraction. The quality of evidence and the absolute effects were quantified using the GRADE system.
The team notes that the certainty for the outcomes identified was moderate to high in each case, but they add that none of the studies reported long-term follow-up, which would be necessary to determine structural valve deterioration.
By Lucy Piper
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