Trends in TAVR and SAVR, Contemporary AS Management Explored in JACC

Important new insights on a hot topic – management of aortic stenosis (AS) via surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) come from three separate articles published Nov. 22 in the Journal of the American College of Cardiology.

The decision to intervene in patients with severe AS was the focus of an analysis conducted by Marc Eugène, MD, and colleagues, using data from the EURObservational Research Programme Valvular Heart Disease (EORP VHD) II Registry. The VHD II survey was conducted between January and August 2017 at 222 centers in 28 countries.

The investigators looked at 1,271 patients with symptomatic high-gradient (≥40 mm Hg) AS who fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines.

A decision not to intervene was seen in about one in five patients (20.6%). Older age, milder AS and heart failure symptoms, and more comorbidities were independently associated with the lack of referral for AVR at the time of index evaluation.

At six months, survival was higher in the group for whom a decision was made to intervene (94.6% vs. 87.4%; p<0.001). “Transcatheter intervention was extensively used in octogenarians,” noted Eugène.

In an accompanying editorial comment, Patrick T. O’Gara, MD, MACC, et al, write that “Eugène, et al., have provided an updated snapshot of AVR referral that can serve as a valuable performance metric. Their findings imply that practice gaps are closing, though there is clear room for further improvement.”

In a separate paper, Makato Mori, MD, and colleagues characterized trends in characteristics and outcomes of Medicare beneficiaries undergoing AVR from 2012 to 2019, a period during which TAVR became increasingly used. The U.S. Food and Drug Administration expanded the indication for TAVR to patients at intermediate risk in 2016 and to patients at low risk in 2019.

Overall, the use of AVR increased by about 60% (from 107 to 156 per 100,000 Medicare beneficiaries), driven by an increased use of TAVR (from 19 to 101 per 100,000 Medicare beneficiaries). SAVR use declined from 88 to 54 per 100,000 Medicare beneficiaries.

For AVR, overall, the median age remained about the same over the study period (rising from 77 to 78 years), but it decreased in both the TAVR group (from 84 to 81 years) and the SAVR group (from 76 to 72 years).

In an editorial comment, Sreekanth Vemulapalli, MD, and Vinod H. Thourani, MD, FACC, cited this finding as proof of the need to analyze TAVR and SAVR characteristics and outcomes together, because looked at in isolation, as most studies have done, “may obscure important truths about the evolution of AVR in the United States.”

Overall, one-year mortality decreased from 11.9% to 9.4%. And by 2019, 54.7% of AVR patients were discharged to home after their procedure, up from 24.2% in 2012, a finding primarily driven by increasing home discharge after TAVR.

In another paper, Andreas Martinsson, MD, PhD, and colleagues looked at patients included in the Swedish Cardiac Surgery Register, part of the SWEDEHEART registry, to determine median survival time in relation to surgical risk and chronological age in SAVR patients.

While several studies have looked at life expectancy after SAVR, both in absolute numbers and in relation to the general population, none have looked at life expectancy in relation to surgical risk combined with chronological age. This information, they write, needs to be considered by the Heart Team during the treatment decision-making process.

After assessing 8,353 patients older than 60 years who underwent isolated SAVR with a bioprosthesis in Sweden between 2001 and 2017 and stratifying them according to age and surgical risk using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and EuroSCORE II, they found that fully 85% were at low risk, 11% were intermediate risk and 4% were high risk.

Median survival in these three groups was 11 years, 7 years and 6 years, respectively, but age at the time of the procedure mattered. Even in the low-risk group, chronological age remained important: median survival time was 16 years in low-risk patients 60-64 years, but was six years in patients older than 85 years.

They concluded the estimated survival is substantial following SAVR, especially in younger, low-risk patients.

“The study by Martinsson, et al., confirms the excellent long-term survival after SAVR, especially in younger and low-risk patients. Robust evidence that long-term outcomes after TAVR are as good as those after SAVR is needed before TAVR should be recommended for these patients,” said Natalie Glaser, MD, PhD, in an accompanying editorial.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure

Keywords: Cardiology, Heart Failure, Registries, Heart Valve Diseases, Heart Valve Prosthesis, Aortic Valve Stenosis, Medicare, United States Food and Drug Administration, Professional Practice Gaps, Life Expectancy, Bioprosthesis, Aortic Valve, Patient Discharge

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