1Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; 2Herzzentrum Leipzig - Universität Leipzig Universitätsklinik für Herzchirurgie Leipzig, Deutschland
Background
Current guidelines recommend transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) as treatment options for severe aortic valve stenosis based on clinical and anatomical characteristics. However, real life data regarding factors affecting the decision making of heart teams and outcomes of patients referred to different treatment pathways is lacking.
Objectives
To characterize and compare outcomes of patients with severe aortic valve disease, referred to the heart team at a large volume centre, according to the received treatment modality.
Methods
Between 2020 and 2022, 3896 patients were evaluated by the local heart-team at a large volume centre for possible TAVR. After excluding patients randomized to TAVR or SAVR within a randomized clinical trial (n=42), the decision of the heart team was to treat 2948 patients (76.5%) with TAVR, 343 patients (8.9%) were referred to SAVR and 563 patients (14.6%) were managed conservatively. We compared baseline characteristics and in-hospital outcome between the first two groups. The cohort referred to SAVR was then further analysed based on indications for surgical referral and type of surgery received.
Results
The total cohort had a median age of 81 (interquartile range [IQR] 76 – 84) years and 44.5% of them were females. Patients referred for TAVR were older (81 [77-84] vs 73 [69-77] years, p<0.001), and more likely to be of female gender (46.2% vs 30.3%, p<0.001). Patients treated with SAVR had lower surgical risk (Society of Thoracic Surgeons score 2.04 [1.364 – 3.45] % vs 3.406 [2.234 – 5.329] %, p<0.001) and were more likely to have bicuspid aortic valve (41.7% vs 8.82%, p<0.001). Patients treated with TAVR more commonly had history of hypertension (94.5% vs 78.1%, p<0.001) and previous surgical coronary revascularization (7.8% vs 0.9%, p<0.001). The most common reasons for referral to SAVR were anatomical factors such as bicuspid aortic valve (41.7%) and severe leaflet or annular calcification (38.5%). Eighteen patients (5.3%) were referred to SAVR due to non-feasibility of a trans-femoral TAVR, while 14 patients (4.1%) were denied TAVR as their annular dimensions were out of range of available percutaneous prostheses. Of the cohort referred to SAVR, 110 patients (32.1%) were younger than 70 years, 127 patients (37%) were aged 70 to 75 years and the remaining 106 patients (30.1%) were older than 75 years. Unfavourable anatomy for TAVR was found in 60%, 61.4% and 62.3% among these age groups, respectively. Almost half of the SAVR patients (47.8%) received an additional surgical intervention, most commonly a coronary bypass (19.5%), followed by concomitant repair or replacement of another severely diseased valve (8.7%). Patients referred to SAVR had longer duration of hospital stay [15 [11 – 20] vs 6 [4 – 8] days, p<0.001) whilst in-hospital mortality was not significantly different (1.16% with SAVR vs 1.42% with TAVR, p=1.000)
Conclusions
In a large multidisciplinary setting, anatomical factors currently represent the most frequent cause of referring elderly patients with severe aortic valve disease to surgical instead of transcatheter valve replacement. Short-term outcomes of both treatment modalities in this setting appear to be comparable.