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TAVR vs. SAVR in Rheumatic Aortic Stenosis
Quick Takes
- In a Medicare cohort of patients, there was no difference in all-cause, in-hospital, or 30-day mortality between patients with rheumatic aortic stenosis (AS) who underwent SAVR vs. TAVR.
- Similarly, there was no difference in all-cause, in-hospital, or 30-day mortality between patients with rheumatic AS vs. nonrheumatic AS who underwent TAVR.
- TAVR in rheumatic AS is associated with similar or lower incidence of most in-hospital complications when compared to TAVR in nonrheumatic AS or to SAVR in rheumatic AS, respectively.
Study Questions:
In a Medicare cohort, what are outcomes of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in patients with rheumatic aortic stenosis (AS), and of TAVR in patients with rheumatic AS vs. nonrheumatic AS?
Methods:
This is a propensity score weighted analysis of Medicare beneficiaries with rheumatic AS who underwent SAVR or TAVR, and of those with rheumatic or nonrheumatic AS who underwent TAVR. Patients who underwent concomitant mitral surgery were excluded. A previously validated frailty score was calculated. The primary outcome was mortality at longest available follow-up. Secondary outcomes included: all-cause mortality, in-hospital mortality, ischemic stroke at 30 days, acute kidney injury (AKI), blood transfusion, new-onset atrial fibrillation (AF), aortic annulus rupture, new permanent pacemaker (PPM) placement, conversion to open surgery, cardiogenic shock, and at longest available follow-up, readmission for heart failure and repeat valve replacement. Cox proportional hazards regression modeling, using patients’ weights to adjust for age, sex, and comorbidities, and competing risk regression analysis were performed.
Results:
From October 2015 to December 2017, 1,159 patients with rheumatic AS underwent aortic valve replacement (SAVR, n = 554; TAVR, n = 605), and 89,159 patients underwent TAVR (nonrheumatic, n = 88,554; rheumatic n = 605). While rheumatic AS patients who underwent SAVR were younger, had less comorbidities, and were less frail than those who underwent TAVR, propensity score weighting created balanced groups. At a median follow-up of 19 months (interquartile range [IQR], 13-26 months), there was no difference in all-cause mortality (TAVR vs. SAVR: 11.2 vs. 7.0 per 100 person-years; adjusted hazard ratio [aHR], 1.53; 95% confidence interval [CI], 0.84-2.79; p = 0.2) and no difference in in-hospital (2.4% vs. 3.5%; p = 0.6) and 30-day (3.6% vs. 3.2%; p = 0.9) mortality or in stroke at 30 days (2.4% vs. 2.8%; p = 0.8). At median follow-up of 10.5 months, there was no difference in risk of heart failure readmission. Incidence of repeat valve replacement in either group was negligible. Patients with rheumatic AS who underwent SAVR had higher weighted risk of in-hospital AKI, blood transfusion, cardiogenic shock, and new-onset AF, and also had longer hospital stay.
After propensity score weighting of patients with rheumatic AS vs. nonrheumatic AS who underwent TAVR, at median follow-up of 17 months (IQR, 11-24 months), there was no difference in all-cause mortality (rheumatic vs. nonrheumatic: 15.2 vs. 17.7 deaths per 100 person-years; aHR, 0.87; 95% CI, 0.68-1.09; p = 0.2) and no difference in in-hospital (2.2% vs. 2.6%; p = 0.7) and 30-day (3.6% vs. 3.7%; p = 0.9) mortality or in 30-day stroke (2.0% vs. 3.3%; p = 0.1). At 9 months, there was no difference in risk of heart failure readmission. While none of the rheumatic AS patients required repeat valve replacement, 242 (0.3%) of nonrheumatic AS patients did. There was no difference in weighted risk of in-hospital AKI, blood transfusion, cardiogenic shock, new-onset AF, aortic annular rupture, and risk of new PPM between the two groups.
Conclusions:
TAVR for rheumatic AS has similar outcomes to SAVR for rheumatic AS, and to TAVR for nonrheumatic AS.
Perspective:
Various factors, including fibrotic rather than calcified leaflets, presence of mixed aortic valve disease and/or multivalvular disease, right ventricular dysfunction, and cardiac structural changes that increase the risk for AF, may complicate successful outcomes of TAVR in rheumatic AS. However, this study shows that TAVR has similar outcomes with regard to mortality and morbidity in this group of patients, who were excluded from the randomized controlled trials. While the authors suggest that TAVR may be a more feasible option than SAVR for treating rheumatic AS in countries where the condition is still highly prevalent, this should be balanced by the current reality that TAVR still requires specialized facilities and operators, the devices are very expensive, and a strategy targeting treatment of Streptococcal infection with antibiotics may be more cost-effective.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease
Keywords: Acute Kidney Injury, Aortic Valve Stenosis, Atrial Fibrillation, Blood Transfusion, Brain Ischemia, Cardiac Surgical Procedures, Conversion to Open Surgery, Frail Elderly, Geriatrics, Heart Failure, Heart Valve Diseases, Hospital Mortality, Length of Stay, Pacemaker, Artificial, Patient Readmission, Shock, Cardiogenic, Stroke, Transcatheter Aortic Valve Replacement
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