Nearly one-half of low-risk patients with severe aortic stenosis (SAS) undergoing surgical aortic valve replacement (SAVR) have at least one of the criteria for exclusion from randomized trials comparing TAVR vs. SAVR. In addition, clinical outcomes may be better than predicted by surgical risk scores, except for patients requiring concomitant mitral or tricuspid valve intervention, according to a study published Jan. 11 in the Journal of the American College of Cardiology.

Alberto Alperi, MD, et al., looked at 6,772 patients in a single center, who had SAS and underwent SAVR between 2000 and 2019. Of these patients, 5,310 (78.4%) exhibited a low-surgical risk (mean Society of Thoracic Surgeons score: 1.94 ± 0.87%).

Results showed in the low-surgical risk SAS group, nearly one-half (40.8%) had at least one of the following criteria: non-trileaflet aortic valve (n=1,468, 27.6%), severe coronary artery disease (n=307, 5.8%), concomitant mitral or tricuspid valve (n=306, 5.8%), and concomitant ascending aorta replacement (n=560, 10.5%).

In addition, the 30-day mortality and stroke rates for the low-surgical risk SAS group were 1.9% and 2.4%, respectively. The mortality rate was similar in the severe coronary artery disease (2.6%) and concomitant ascending aorta replacement (2.1%) groups vs. the rest of the cohort, lower in the non-trileaflet aortic valve group, and higher in the concomitant mitral or tricuspid valve group.

The authors conclude that moving forward, "these results should be considered in the expansion of TAVR toward the treatment of low-risk patients and may inform future randomized trials according to specific clinical variables, particularly in the presence of [non-trileaflet aortic valve, concomitant mitral or tricuspid valve, and severe coronary artery disease]."

In a related editorial comment, Poonam Velagapudi, MD, MS, FACC, et al., add that "TAVR has established itself as an important part of the treatment algorithm in patients with SAS. However, as highlighted by Alperi et al., there are important subgroups of patients with SAS that have not been studied in [randomized control trials] to date." They explain that until results from clinical trials for these subgroups are developed and released, "low-risk patients undergoing TAVR must be carefully selected by the heart team based on patient and anatomic factors with a thorough discussion of risks versus benefits; SAVR remains the treatment of choice in certain clinical situations."

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease

Keywords: Aortic Valve, Transcatheter Aortic Valve Replacement, Tricuspid Valve, Coronary Artery Disease, Aortic Valve Stenosis, Heart Valve Prosthesis, Heart Valve Diseases, Risk Factors, Stroke, Aorta, Cardiology, Surgeons

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