Clinical Outcomes of Patients With Severe Aortic Stenosis at Increased Surgical Risk According to Treatment Modality

• Published in: Journal of the American College of Cardiology Vol. 58; no. 21; pp. 2151 - 2162
• Main Authors: Wenaweser, Peter, MD, Pilgrim, Thomas, MD, Kadner, Alexander, MD, Huber, Christoph, MD, Stortecky, Stefan, MD, Buellesfeld, Lutz, MD, Khattab, Ahmed A., MD, Meuli, Fabienne, MS, Roth, Nadja, MS, Eberle, Balthasar, MD, Erdös, Gabor, MD, Brinks, Henriette, MD, Kalesan, Bindu, PhD, Meier, Bernhard, MD, Jüni, Peter, MD, Carrel, Thierry, MD, Windecker, Stephan, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 15.11.2011; Elsevier Limited
• Subjects: Age; Aged; Aged, 80 and over; aortic stenosis; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Atrial Fibrillation - epidemiology; Atrial Fibrillation - etiology; Cardiac Catheterization - adverse effects; Cardiology; Cardiovascular; Cardiovascular disease; Clinical outcomes; Comorbidity; Confidence intervals; Coronary vessels; Diabetes; Drug therapy; Female; Follow-Up Studies; Heart failure; Heart surgery; Heart Valve Prosthesis - adverse effects; Hospital Mortality - trends; Humans; Hypertension; Internal Medicine; Liver cirrhosis; Male; Medical prognosis; Mortality; Prospective Studies; Radiation therapy; Risk assessment; Severity of Illness Index; Stroke; surgical aortic valve replacement; Switzerland - epidemiology; transcatheter aortic valve implantation; Treatment Outcome; Switzerland; major adverse cerebro-cardiovascular event(s); medical treatment; European System for Cardiac Operative Risk Evaluation; myocardial infarction; TAVI; MACCE; RIFLE; Edwards Sapien valve; URL; percutaneous coronary intervention; aortic stenosis; Risk, Injury, Failure, Loss, End-stage kidney disease; MI; coronary artery bypass grafting; transcatheter aortic valve implantation; computed tomography; CI; PRBC; Medtronic CoreValve Revalving system; MT; ESV; SAVR; packed red blood cells; CT; AS; MCRS; PCI; EuroSCORE; upper reference limit; confidence interval; surgical aortic valve replacement; CABG
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2011.05.063

Objectives The aim of this study was to assess the role of transcatheter aortic valve implantation (TAVI) compared with medical treatment (MT) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) at increased surgical risk. Background Elderly patients with comorbidities are at considerable risk for SAVR. Methods Since July 2007, 442 patients with severe AS (age: 81.7 ± 6.0 years, mean logistic European System for Cardiac Operative Risk Evaluation: 22.3 ± 14.6%) underwent treatment allocation to MT (n = 78), SAVR (n = 107), or TAVI (n = 257) on the basis of a comprehensive evaluation protocol as part of a prospective registry. Results Baseline clinical characteristics were similar among patients allocated to MT and TAVI, whereas patients allocated to SAVR were younger (p < 0.001) and had a lower predicted peri-operative risk (p < 0.001). Unadjusted rates of all-cause mortality at 30 months were lower for SAVR (22.4%) and TAVI (22.6%) compared with MT (61.5%, p < 0.001). Adjusted hazard ratios for death were 0.51 (95% confidence interval: 0.30 to 0.87) for SAVR compared with MT and 0.38 (95% confidence interval: 0.25 to 0.58) for TAVI compared with MT. Medical treatment (<0.001), older age (>80 years, p = 0.01), peripheral vascular disease (<0.001), and atrial fibrillation (p = 0.04) were significantly associated with all-cause mortality at 30 months in the multivariate analysis. At 1 year, more patients undergoing SAVR (92.3%) or TAVI (93.2%) had New York Heart Association functional class I/II as compared with patients with MT (70.8%, p = 0.003). Conclusions Among patients with severe AS with increased surgical risk, SAVR and TAVI improve survival and symptoms compared with MT. Clinical outcomes of TAVI and SAVR seem similar among carefully selected patients with severe symptomatic AS at increased risk.