Concordance of Guideline-Based Risk Stratification and Selection of Patients for Transcatheter Aortic Valve Implantation or Surgical Replacement

Transcatheter Aortic Valve Implantation in Patients at Intermediate and Low Risk Is Not (Yet) the Existential Threat That Surgeons Feared: A Retrospective Analysis of Medicare Claims Data

BACKGROUND

In Australia, the role of surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in patients who are suitable for both procedures remains controversial. In 2022, new Items were added to the Medicare Benefits Schedule (MBS) to allow patients at intermediate and low risk with appropriate private health insurance to undergo TAVI. The Cardiac Society of Australia and New Zealand supported these changes whereas the Australian and New Zealand Society of Cardiac and Thoracic Surgeons opposed them. The aim of this study was to document subsequent private TAVI activity in patients at intermediate and low risk, relative to both private TAVI activity in patients at high risk and private SAVR activity.

METHOD

A retrospective population-level descriptive study was undertaken, using Medicare claims data obtained from Services Australia.

RESULTS

Among private patients who underwent TAVI, the groups at high, intermediate, and low risk all had a median age between 75 and 84 years. Only 1% were aged ≤64 years (86/6,586), and 80% of these were at high risk (69/86). Among private patients at intermediate and low risk who underwent TAVI and private patients who underwent SAVR, only 4% of patients aged 55-64 years chose private TAVI over private SAVR (8/211), and 63% of these were at intermediate risk (5/8).

CONCLUSIONS

The introduction of MBS Items for private TAVI in patients at intermediate and low risk without accompanying age exclusion criteria has not (yet) had a major impact on private SAVR activity. This suggests that the multidisciplinary heart team (TAVI case conference) approval process remains an effective mechanism for ensuring access to private TAVI is consistent with international guidelines.

Impact of cerebral protection on observed versus predicted in-hospital stroke in a high stroke risk TAVR cohort

BACKGROUND

Despite impressive improvements in the safety profile of Transcatheter aortic valve replacement (TAVR), the risk for peri-procedural stroke after TAVR has not declined substantially. In an effort to reduce periprocedural stroke, cerebral embolic protection (CEP) devices have been utilized but have yet to demonstrate benefit in all-comers. There is a paucity of data supporting the utilization of CEP in TAVR patients with an anticipated high risk for peri-procedural stroke.

METHODS

The Transcatheter Aortic Valve Replacement In-Hospital Stroke (TASK) score is a clinical risk tool for predicting the in-hospital stroke risk of patients undergoing transfemoral TAVR. This score was used to identify high-risk patients and calculate the expected in-hospital stroke risk. This was a single-centre cohort study in all consecutive TAVR patients who had placement of CEP. The observed versus expected ratio for peri-procedural stroke was calculated. To obtain 95% credible intervals, we used 1000 bootstrapped samples of the original cohort sample size without replacement and recalculated the TASK predicted scores.

RESULTS

The study included 103 patients. The median age was 83 (IQR 78,89). 63 were male (61.1%) and 45 (43.69%) had a history of previous Stroke or TIA. Two patients had an in-hospital stroke after TAVR (1.94%). The expected risk of in-hospital stroke based on the TASK score was 3.39% (95% CI 3.07-3.73). The observed versus expected ratio was 0.57 (95% CI 0.52-0.64).

CONCLUSION

In this single-center study, we found that in patients undergoing TAVR with high stroke risk, CEP reduced the in-hospital stroke risk by 43% when compared with the risk-score predicted rate.

CLINICAL TRIAL NUMBER

N/A.

National Trends and Outcomes of Acute Myocardial Infarction After Transcatheter Aortic Valve Replacement

BACKGROUND

Prior studies have reported decreased use of an invasive approach for acute myocardial infarction (AMI) in patients undergoing transcatheter aortic valve replacement (TAVR).

OBJECTIVES

The aim of this study was to determine whether prior TAVR affects the use of subsequent coronary revascularization and outcomes of AMI in a contemporary national data set.

METHODS

Consecutive TAVR patients from 2016 to 2022 were identified from the U.S. Vizient Clinical Data Base who were hospitalized after the index TAVR hospitalization with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI). Patients with STEMI or NSTEMI with or without prior TAVR from the same time period were compared for the use of coronary angiography, revascularization, and in-hospital outcomes. Propensity score matching was used to account for imbalances in patient characteristics.

RESULTS

Among 206,229 patients who underwent TAVR, the incidence of STEMI was 25 events per 100,000 person-years of follow-up, and that of NSTEMI was 229 events per 100,000 person-years. After propensity matching, the use of coronary revascularization was similar in the prior TAVR and no TAVR cohorts in both the STEMI (65.3% vs 63.9%; P = 0.81) and NSTEMI (41.4% vs 41.7%; P = 0.88) subgroups. Compared with patients without prior TAVR, in-hospital mortality was higher in the prior TAVR cohort in patients with STEMI (27.1% vs 16.7%; P = 0.03) and lower in those with NSTEMI (5.8% vs 8.2%; P = 0.02).

CONCLUSIONS

In this large, national retrospective study, AMI events after TAVR were infrequent. There were no differences in the use of coronary revascularization for STEMI or NSTEMI in TAVR patients compared with the non-TAVR population. In-hospital mortality for STEMI is higher in TAVR patients compared with those without prior TAVR.

Transcatheter aortic valve implantation (from inception to standard treatment): a single-center observational study

Background

Treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) was introduced in 2002. Since then, TAVI has become the primary treatment approach worldwide for advanced-age patients and younger patients with severe comorbidities. We aimed to evaluate the changes in patient demographics, complications, and mortality rates within 13 years.

Methods

This retrospective observational study included 867 patients who underwent TAVI at the University Hospital of North Norway in Tromsø from 2008 to 2021. The 13-year period was divided into period 1 (2008-2012), period 2 (2013-2017), and period 3 (2018-2021). The primary objective was to evaluate the changes in periprocedural (30 days), early (30-365 days), and late mortality rates (>365 days) between the periods. The secondary objective was to evaluate late mortality rates by sex and age groups: <70 years, 70-79 years, 80-89 years, and ≥90 years.

Results

The periprocedural mortality rates for periods 1, 2, and 3 were 10.3%, 2.9%, and 1.2%, respectively (P < 0.001). The early mortality rates were 5.6%, 5.8%, and 6.5%, respectively. No significant differences were observed in late mortality by sex or age group (<70, 70-79, and 80-89 years) with a median survival of 5.3-5.6 years. The median survival in patients aged ≥90 years was 4.0 years (P = 0.018).

Conclusion

Our findings indicate that most patients are octogenarians, and the burden of their comorbidities should be highly considered compared to their age when evaluating the procedural outcomes. As the incidence of most complications related to TAVI has decreased, the rates of permanent pacemaker implantation remain high. Important advancements in diagnostics, valve technology, and procedural techniques have improved the periprocedural mortality rates; however, early mortality remains unchanged and poses a clinical challenge that needs to be addressed in the future.

Patterns of Aortic Valve Replacement in Europe: Adoption by Age

INTRODUCTION

The management of patients with severe aortic stenosis may differ according to patients' age. The aim of this analysis was to describe patterns of aortic valve replacement (AVR) use in European countries stratified by age.

METHODS

Procedure volume data for AVR, including surgical aortic valve replacement (sAVR) and transcatheter aortic valve implantation (TAVI), for the years 2015-2020 were obtained from national databases for twelve European countries (Austria, the Czech Republic, Denmark, England, Finland, France, Germany, Norway, Poland, Spain, Sweden, and Switzerland). Procedure volumes were reported by patient age (<50 years, 5-year age groups between 50 and 85 years, and ≥85 years). Patients per million (PPM) population undergoing AVR each year were calculated using population estimates from Eurostat.

RESULTS

AVR PPM varied widely between countries, from 508 PPM in Germany to 174 PPM in Poland in 2020. TAVI rates ranged from 61% in Switzerland and Finland to 25% in Poland. AVR PPM increased with age to a peak at 80-84 years, after which it decreased again. AVR procedures increased from 2015 to 2019 at an average annual rate of 3.9%. AVR increased more substantially in people aged ≥80 years than in younger age groups; these older age groups accounted for 30% of all AVR procedures in 2015 and 35% in 2019. TAVI accounted for an increasing proportion of all AVR procedures as patient age increased; an overall average of 96% of males and 98% of females aged ≥85 years received TAVI as the treatment modality, although adoption of TAVI differed between countries.

CONCLUSIONS

There is considerable variation in the rates of AVR use and the adoption of TAVI versus sAVR between European countries. The use of TAVI has increased in recent years, particularly for older patients.