TAVI May Hold Benefits Over Surgical Aortic Valve Replacement

A new study suggests that patients with severe aortic stenosis may have more to gain from transfemoral transcatheter aortic valve implantation (TAVI) than surgical replacement.

Researchers at McMaster University (Hamilton, ON, Canada), Jagiellonian University (Krakow, Poland), and other institutions conducted a systematic review of four trials with 3,179 patients and a median follow-up of two years to compare TAVI and surgical replacement of an aortic valve (SAVR) in patients with severe aortic stenosis (most of whom older than 80 years of age) who were at low and intermediate risk of perioperative death (i.e., less than 8%). Two reviewers independently extracted data and assessed risk of bias for outcomes important to the patients, which were selected a priori.

The results revealed that over a median follow-up of two years, transfemoral TAVI was associated with better outcomes than SAVR in terms of mortality, stroke, acute kidney injury (AKI), and bleeding. Among the 1,578 patients undergoing TAVI there were an estimated 30 fewer deaths per 1,000 patients than among the 1,550 undergoing SAVR, while for stroke, AKI, and bleeding, there were 20, 53, and 252 fewer instances (respectively). The occurrence of new-onset atrial fibrillation (AF) was also reduced, with 178 fewer instances. The study was published on September 28, 2016, in BMJ.

“The benefits of transfemoral TAVI over SAVR, and the fact that it is less invasive, are likely to make it more compelling for older patients, such as those aged over 85 years. SAVR, however, performs better than transapical TAVI, which is of interest to patients who are not candidates for transfemoral TAVI,” concluded lead author Reed Siemieniuk, MD, of McMaster, and colleagues. “Younger patients, for whom valve longevity could be extremely important, may be more likely to choose SAVR.”

TAVI involves the percutaneous insertion of a catheter containing a replacement valve through the groin or chest; the new valve is pushed into the correct site, where the surgeon expands it into position. TAVI is an increasingly popular alternative to open surgery, as it does not require thoracotomy or a heart-lung machine. Guidelines recommend both TAVI and SAVR in patients in high surgical risk, but recommend SAVR over TAVI for lower risk patients. But despite this recommendation, half of the TAVI centers in Europe perform TAVI in intermediate risk patients, and 10% of centers do so in low risk patients.

Related Links:
McMaster University
Jagiellonian University