TAVR vs. SAVR Propensity-Matched Comparison

Study Questions:

What is the safety and effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) for treatment of aortic stenosis in intermediate- and high-risk patients?

Methods:

Data were drawn from two US procedural registries: SAVR data were drawn from the Society of Thoracic Surgeons (STS) National Database, and TAVR data were drawn from the STS/American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry (linked to Medicare reimbursement). Death, stroke, days alive and out of hospital (DAOH) to 1 year, and discharge to home were compared for 9,464 propensity-matched intermediate- and high-risk (STS Predicted Risk of Mortality [PROM] ≥3%) patients who underwent commercial TAVR or SAVR, with subgroup analyses by surgical risk, demographics, and comorbidities. Patients with characteristics thought to strongly favor one treatment or another (age <65 or >90 years, other major cardiac operations, history of endocarditis, emergency or salvage status, primary aortic insufficiency, hostile chest or porcelain aorta, moderate or severe mitral stenosis) were excluded, yielding a total of 17,910 TAVR and 22,618 SAVR patients available for propensity matching.

Results:

The propensity-matched cohort included 4,732 SAVR and 4,732 TAVR patients, with median age 82 years (interquartile range [IQR], 77-85 years), 47.9% women, and median STS PROM 5.6% (4.2-8.2%). TAVR and SAVR patients experienced no difference in 1-year rates of death (17.3% vs. 17.9%; hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.83-1.04) and stroke (4.2% vs. 3.3%; HR, 1.18; 95% CI, 0.95-1.47), and no difference in the proportion of DAOH to 1 year (rate ratio, 1.00; 95% CI, 0.98-1.02). However, TAVR patients were more likely to be discharged home after treatment (69.9% vs. 41.2%; odds ratio, 3.19; 95% CI, 2.84-3.58). Results were consistent across most subgroups, including among intermediate- and high-risk patients.

Conclusions:

Among unselected intermediate- and high-risk patients, TAVR and SAVR resulted in similar rates of death, stroke, and DAOH to 1 year; but TAVR patients were more likely to be discharged to home.

Perspective:

Three high-quality randomized, controlled trials have supported the use of TAVR in intermediate- and high-risk patients; however, patient groups with higher-risk comorbidities were excluded, and the studies were performed at a select set of high-volume centers. This study, using observational data from two large US procedural registries and propensity matching suggests that, among patients with intermediate or high surgical risk, TAVR and SAVR have similar rates of death, stroke, and DAOH to 1 year; and that TAVR patients were more likely to be discharged to home. These data help support the generalizability of the randomized, controlled trial data to clinical practice.


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