[Reducing the risk of vascular complications during percutaneous aortic valve replacement]

Outcomes of Aortic Valve Replacement According to Surgical Approach in Intermediate and Low Risk Patients: A Propensity Score Analysis

BACKGROUND

Previous trials have shown that, among high-risk patients with aortic stenosis, survival rates are similar for transcatheter aortic-valve implantation (TAVI) and surgical aortic valve replacement. The study aimed to compare the outcomes of aortic valve replacement according to the adopted surgical approach in intermediate and low risk patients.

METHODS

This is a retrospective, observational, cohort study of prospectively collected data from 421 patients undergoing isolated aortic valve replacement between 2011 and 2015. A multinomial logit propensity score model based on preoperative risk factors was used to match patients 1:1:1 between conventional replacement (CAVR), minimally invasive (MIAVR) and TAVI groups, resulting in 50 matched three cohorts.

RESULTS

After multinomial logit propensity score, the three groups were comparable in terms of preoperative characteristics. Mean age and Logistic EuroSCORE I of CAVR, MIAVR and TAVI groups were (84.2±5.1 vs. 82.3±4.8 vs. 85.6±4.9 years; p=0.002) and (11.4±3.6% vs. 8.3±3.4% vs. 15.8±5.4%; p<0.001) respectively. Overall mortality rates were similar for the three patient cohorts at one year. There were no significant differences related to stroke to 30 days. In the TAVI cohort, pacemaker implantation for new-onset total atrioventricular block became necessary in 30% of patients (p<0.001) and 16% of patients had some degree of paravalvular aortic regurgitation, which was more than mild (p<0.001). Total length of stay was shorter in the TAVI group when compared with surgical groups (11.5±5.3 vs. 10.1±6.9 vs 8.5±3.7 days; p=0.023). After discharge, the survival rate follow-up (average follow up: 46.7 months) was 70%, 84% and 72% for three cohorts (log Rank x²=2.40, p=0.3).

CONCLUSIONS

In our experience, the three aortic valve replacement approaches offer very good results. Differences in the rate of complications were found between groups. Depending on patient's characteristics the Heart-Team group must offer the best surgical approach for each patient.

Transcatheter Aortic Valve Implantation (TAVI): Is it Time for This Intervention to be Applied in a Lower Risk Population?

Patients with severe aortic stenosis are sometimes not candidates for conventional open heart surgery because of severe deconditioning, excessive risk factors, and multiple comorbidities. Transcatheter aortic valve implantation (TAVI) is a relatively recent intervention, which was initially addressed to individuals with severe symptomatic aortic stenosis at substantial or prohibitive surgical risk. Despite the documented beneficial effects of this therapeutic intervention in certain carefully selected individuals, it has not yet been applied to lower risk patients. This is a review of the current literature and accumulated clinical data of this rapidly evolving invasive procedure in an attempt to resolve whether it can now be applied to a wider portion of patients with aortic stenosis.

A review of most relevant complications of transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has emerged for treating aortic stenosis in patients who are poor candidates for surgical aortic valve replacement. Currently, the balloon-expandable Edwards Sapien valve—which is usually implanted via a transfemoral or transapical approach—and the self-expanding CoreValve ReValving system—which is designed for retrograde application—are the most widely implanted valves worldwide. Although a promising approach for high-risk patients, the indication may be expanded to intermediate- and eventually low-risk patients in the future; however, doing so will require a better understanding of potential complications, risk factors for these complications, and strategies to individualize each patient to a different access route and a specific valve. This paper reviews the most relevant complications that may occur in patients who undergo catheter-based aortic valve implantation.