|
3
|
Rodés-Cabau J, Ribeiro HB, Mohammadi S, Serra V, Al-Atassi T, Iñiguez A, Vilalta V, Nombela-Franco L, Sáez de Ibarra Sánchez JI, Auffret V, Forcillo J, Conradi L, Urena M, Moris C, Muñoz-Garcia A, Paradis JM, Dumont E, Kalavrouziotis D, Maria Pomerantzeff P, Rosa VEE, Pezzute Lopes M, Sureda C, Diaz VAJ, Giuliani C, Avvedimento M, Pelletier-Beaumont E, Pibarot P. Transcatheter or Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis and Small Aortic Annulus: A Randomized Clinical Trial. Circulation 2024; 149:644-655. [PMID: 37883682 DOI: 10.1161/circulationaha.123.067326] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The optimal treatment in patients with severe aortic stenosis and small aortic annulus (SAA) remains to be determined. This study aimed to compare the hemodynamic and clinical outcomes between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with a SAA. METHODS This prospective multicenter international randomized trial was performed in 15 university hospitals. Participants were 151 patients with severe aortic stenosis and SAA (mean diameter <23 mm) randomized (1:1) to TAVR (n=77) versus SAVR (n=74). The primary outcome was impaired valve hemodynamics (ie, severe prosthesis patient mismatch or moderate-severe aortic regurgitation) at 60 days as evaluated by Doppler echocardiography and analyzed in a central echocardiography core laboratory. Clinical events were secondary outcomes. RESULTS The mean age of the participants was 75.5±5.1 years, with 140 (93%) women, a median Society of Thoracic Surgeons predicted risk of mortality of 2.50% (interquartile range, 1.67%-3.28%), and a median annulus diameter of 21.1 mm (interquartile range, 20.4-22.0 mm). There were no differences between groups in the rate of severe prosthesis patient mismatch (TAVR, 4 [5.6%]; SAVR, 7 [10.3%]; P=0.30) and moderate-severe aortic regurgitation (none in both groups). No differences were found between groups in mortality rate (TAVR, 1 [1.3%]; SAVR, 1 [1.4%]; P=1.00) and stroke (TAVR, 0; SAVR, 2 [2.7%]; P=0.24) at 30 days. After a median follow-up of 2 (interquartile range, 1-4) years, there were no differences between groups in mortality rate (TAVR, 7 [9.1%]; SAVR, 6 [8.1%]; P=0.89), stroke (TAVR, 3 [3.9%]; SAVR, 3 [4.1%]; P=0.95), and cardiac hospitalization (TAVR, 15 [19.5%]; SAVR, 15 [20.3%]; P=0.80). CONCLUSIONS In patients with severe aortic stenosis and SAA (women in the majority), there was no evidence of superiority of contemporary TAVR versus SAVR in valve hemodynamic results. After a median follow-up of 2 years, there were no differences in clinical outcomes between groups. These findings suggest that the 2 therapies represent a valid alternative for treating patients with severe aortic stenosis and SAA, and treatment selection should likely be individualized according to baseline characteristics, additional anatomical risk factors, and patient preference. However, the results of this study should be interpreted with caution because of the limited sample size leading to an underpowered study, and need to be confirmed in future larger studies. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03383445.
Collapse
Affiliation(s)
- Josep Rodés-Cabau
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Henrique Barbosa Ribeiro
- Interventional Cardiology Department, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil (H.B.R., P.M.P., V.E.E.R., M.P.L.)
| | - Siamak Mohammadi
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Vicenç Serra
- Cardiology Department, Vall d'Hebron University Hospital, Barcelona, Spain (V.S., C.S.)
| | - Talal Al-Atassi
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (T.A.-A.)
| | - Andres Iñiguez
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Spain (A.I., V.A.J.D.)
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain (A.I., V.A.J.D.)
| | - Victoria Vilalta
- Department of Interventional Cardiology, Germans Trias i Pujol University Hospital, Badalona, Spain (V.V.)
| | - Luis Nombela-Franco
- Interventional Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain (L.N.-F.)
| | | | - Vincent Auffret
- Department of Cardiology, Rennes University Hospital, Rennes, France (V.A.)
| | - Jessica Forcillo
- Department of Cardiac Surgery, Centre Hospitalier Universitaire de Montreal, Montreal, Canada (J.F.)
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany (L.C.)
| | - Marina Urena
- Department of Cardiology, Hospital Bichat Claude-Bernard, Paris, France (M.U.)
| | - Cesar Moris
- Department of Cardiology, University Hospital Central de Asturias, Oviedo, Spain (C.M.)
| | - Antonio Muñoz-Garcia
- Cardiology Department, University Hospital Virgen de la Victoria, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, (CIBERCV), Málaga, Spain (A.M.-G.)
| | - Jean-Michel Paradis
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Eric Dumont
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Dimitri Kalavrouziotis
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Pablo Maria Pomerantzeff
- Interventional Cardiology Department, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil (H.B.R., P.M.P., V.E.E.R., M.P.L.)
| | - Vitor Emer Egypto Rosa
- Interventional Cardiology Department, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil (H.B.R., P.M.P., V.E.E.R., M.P.L.)
| | - Mariana Pezzute Lopes
- Interventional Cardiology Department, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil (H.B.R., P.M.P., V.E.E.R., M.P.L.)
| | - Carles Sureda
- Cardiology Department, Vall d'Hebron University Hospital, Barcelona, Spain (V.S., C.S.)
| | - Victor Alfonso Jimenez Diaz
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Spain (A.I., V.A.J.D.)
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain (A.I., V.A.J.D.)
| | - Carlos Giuliani
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Marisa Avvedimento
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Emilie Pelletier-Beaumont
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| | - Philippe Pibarot
- Cardiology Department, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada (J.R.-C., S.M., J.-M.P., E.D., D.K., C.G., M.A., E.P.-B., P.P.)
| |
Collapse
|