Transcatheter (TAVR) Versus Surgical (AVR) Aortic Valve Replacement: Occurrence, Hazard, Risk Factors, and Consequences of Neurologic Events in the PARTNER Trial

Apr 13, 2012
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Authors:
Miller C, Blackstone E, Mack M, et al., on behalf of the PARTNER Trial Investigators and Patients, the PARTNER Stroke Substudy Writing Group and Executive Committee.
Citation:
J Thorac Cardiovasc Surg 2012;143:832-843.
Summary By:
Hitinder S. Gurm, MBBS, FACC

Study Questions:

What are the predictors of stroke in patients undergoing surgical aortic valve replacement (surgical AVR) versus transcatheter aortic valve replacement (TAVR)?

Methods:

The authors evaluated the predictors and implications of stroke in all patients (n = 657) randomized to the PARTNERS trial. Surgical AVR was performed in 313 patients, and 344 underwent TAVR. Neurologic events were prospectively adjudicated by an independent clinical events committee. Multivariable, multiphase hazard analysis was performed to define predictors of neurologic events.

Results:

A total of 49 neurologic events (15 transient ischemic attacks, 34 strokes) occurred in 47 patients (TAVR, n = 31; AVR, n = 16). There was an early peaking high hazard phase within the first week, followed by a lower but constant hazard phase out to 2 years. The risk in the early phase was higher after TAVR than surgical AVR, and in the TAVR arm in patients with a smaller aortic valve area index. In the late risk phase, the likelihood of neurologic event was linked to patient-related factors in both arms ("non-Trans-femoral candidate," history of recent stroke or transient ischemic attack, and advanced functional disability), but not by treatment (TAVR vs. surgical AVR) or any intraprocedural variables.

Conclusions:

In patients undergoing TAVR or surgical AVR, there were two distinct hazard phases for neurologic events. Early neurologic complications occurred more frequently after TAVR than AVR, but the late risk was influenced by patient- and disease-related factors.

Perspective:

Stroke is a major complication associated with TAVR, and is more frequently seen compared with surgical AVR. An increasing awareness of this complication has resulted in efforts to reduce this risk, and future studies will determine whether improvement in device design, smaller delivery systems, embolic protection devices, better patient selection, and increased operator experience can reduce the incidence of neurologic complications after TAVR.

Keywords: Heart Valve Prosthesis, Nervous System Diseases, Stroke, Embolic Protection Devices, Ischemic Attack, Transient, Patient Selection, Cardiology, Risk Factors, Angioplasty, Equipment Design


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