Transcatheter vs. Surgical Pulmonary Valve Replacement

Study Questions:

What are the predictors of morbidity and mortality in patients undergoing either transcatheter pulmonary valve replacement (TPVR) or surgical pulmonary valve replacement (SPVR)?

Methods:

A retrospective cohort study was performed at a single center. A risk-adjusted propensity-score model was used to compare a composite endpoint of in-hospital major morbidity and 30-day mortality between patients undergoing SPVR and TPVR between January 2006 and January 2014.

Results:

A total of 223 patients were included, of which 145 underwent SPVR and 78 underwent TPVR. Primary pulmonary regurgitation was more common in the SPVR group (76.6% as compared with 23.1%, p < 0.001), while primary pulmonary stenosis was more common in the TPVR group (9.7% as compared with 44.9%, p < 0.001). In unadjusted analysis, mortality and major morbidity were more common in patients undergoing SPVR (11.7% vs. 3.8%, p = 0.04). With propensity-score analysis, no significant difference was seen between the surgical and transcatheter groups. Hospital length of stay was shorter in the TPVR group (1.2 ± 0.3 days vs. 6.9 ± 1.1 days), although there was no difference in total costs (US $48,355 ± 1,000 for the TPVR group and US $44,660 ± 5,071 for the SPVR group).

Conclusions:

The authors concluded that, after risk adjustment, there were no differences in outcomes between transcatheter and surgical approaches to pulmonary valve replacement. While transcatheter procedures were associated with shorter hospital stay, there was no difference in hospital costs.

Perspective:

TPVR has essentially become a first-line therapy for PVR in patients with suitable anatomy, particularly those who have already had surgical placed conduits or valves in the right ventricular outflow tract. Interestingly, despite a significantly shorter length of stay, there was no cost benefit for TPVR, largely due to the high cost of the valves. The study was not randomized, and, specifically, patients were chosen for TPVR if the anatomy was suitable and SPVR if it was not. Despite the use of propensity-score adjustment, it is possible that unknown variables may have influenced the results of the study. Additionally, longer-term follow-up will be required, specifically investigating issues such as endocarditis after TPVR.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD & Pediatrics and Interventions, CHD & Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Cardiac Surgical Procedures, Cost-Benefit Analysis, Endocarditis, Heart Defects, Congenital, Heart Valve Diseases, Length of Stay, Morbidity, Mortality, Pulmonary Valve, Pulmonary Valve Insufficiency, Pulmonary Valve Stenosis, Risk Adjustment, Treatment Outcome


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