Effect of TAVR Availability on Clinical Practice
How does the introduction of transcatheter aortic valve replacement (TAVR) affect clinical practice compared to the effect of surgical aortic valve replacement (SAVR)?
Data were extracted from an inclusive nationwide German databank for billing that includes diagnoses, coexistent conditions, and procedures. Patient characteristics and in-hospital outcomes were examined for all isolated TAVR and isolated SAVR procedures performed in Germany from 2007 to 2013.
In total, 32,581 TAVR and 55,992 SAVR procedures were performed. The number of TAVR procedures increased from 144 in 2007 to 9,147 in 2013, whereas the number of SAVR procedures decreased slightly, from 8,622 to 7,048. Patients undergoing TAVR were older than those undergoing SAVR (mean age 81.0 ± 6.1 years vs. 70.2 ± 10.0 years) and at higher preoperative risk (estimated logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 22.4% vs. 6.3% [on a scale of 0 to 100%, with higher scores indicating greater risk, and a score of >20% indicating high surgical risk]). In-hospital mortality decreased in both groups between 2007 and 2013 (from 13.2% to 5.4% with TAVR, and from 3.8% to 2.2% with SAVR). The incidences of stroke, bleeding, and pacemaker implantation (but not acute kidney injury) also declined.
The use of TAVR increased markedly in Germany between 2007 and 2013; the concomitant reduction in the use of SAVR was only moderate. Patients undergoing TAVR were older and at higher procedural risk than those undergoing SAVR. In-hospital mortality decreased in both groups over the studied time interval, but to a greater extent among patients undergoing TAVR.
The adoption of TAVR in the European Union has been heterogeneous, but in Germany, it has been brisk (see Mylotte D, et al., J Am Coll Cardiol 2013;62:210-9). These data provide reassurance that TAVR has been used for the most part among patients previously denied SAVR or at high risk for SAVR. The availability of TAVR for high-risk patients likely contributes to the temporal decline in mortality associated with SAVR. The observed temporal decline in mortality associated with TAVR likely is due to operator experience and improvement in devices, with a possible contribution of younger and therefore presumably lower-risk patients undergoing TAVR in more recent years.
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