Long-Term Outcomes After Transcatheter Aortic Valve Implantation from a Single High-Volume Center (The Milan Experience)

A comparative profitability analysis of transcatheter versus surgical aortic valve replacement in a high-volume French hospital

BACKGROUND

Current scientific guidelines have extended the indication for transcatheter aortic valve replacement (TAVR) to patients who present an intermediate risk for surgery and have been so far considered for conventional surgery. We previously demonstrated that the TAVR procedure generated profits despite elevated costs, but comparison with surgery has not been performed. The objective of this study was to assess the profitability of the TAVR procedure compared with conventional surgery in a high-volume French hospital. Consecutive patients eligible for transfemoral TAVR or surgical aortic valve replacement (SAVR) were included retrospectively in this single-centre study between September 2014 and December 2015. The primary endpoint was the profitability of each procedure (defined as the ratio between the profit and total revenues), calculated for each patient. Secondary composite endpoints included major adverse events in the 30 days following procedure and breakdown of costs.

RESULTS

Two hundred and thirty-eight patients were included in the TAVR group and 341 in the SAVR group. TAVR patients presented higher operative risk scores and more comorbidities. Compared with SAVR, TAVR was associated with higher profits (€2732 ± 1768 per patient vs. €2177 ± 2437 per patient, P < 0.001) but also higher costs (€27,778 ± 4961 vs. €17,813 ± 6071, P < 0.001) resulting in lower profitability (9.3 ± 5.7% vs. 11.7 ± 10.1%, P < 0.001). The price of the bioprosthesis represented 70% of the TAVR total cost.

CONCLUSIONS

TAVR performed in carefully selected patients was associated with higher profits than SAVR, but also higher costs resulting in lower profitability.

Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond

BACKGROUND

Transcatheter aortic valve implantation/replacement (TAVI/TAVR) is becoming more frequently used to treat aortic stenosis (AS), with increasing push for the procedure in lower risk patients. Numerous randomized controlled trials have demonstrated that TAVI offers a suitable alternative to the current gold standard of surgical aortic valve replacement (SAVR) in terms of short-term outcomes. The present review evaluates long-term outcomes following TAVI procedures.

METHODS

Literature search using three electronic databases was performed up to June 2017. Studies which included 20 or more patients undergoing TAVI procedures, either as a stand-alone or concomitant procedure and with a follow-up of at least 5 years, were included in the present review. Literature search and data extraction were performed by two independent researchers. Digitized survival data were extracted from Kaplan-Meier curves in order to re-create the original patient data using an iterative algorithm and subsequently aggregated for analysis.

RESULTS

Thirty-one studies were included in the present analysis, with a total of 13,857 patients. Two studies were national registries, eight were multi-institutional collaborations and the remainder were institutional series. Overall, 45.7% of patients were male, with mean age of 81.5±7.0 years. Where reported, the mean Logistic EuroSCORE (LES) was 22.1±13.7 and the mean Society of Thoracic Surgeons (STS) score was 9.2±6.6. The pooled analysis found 30-day mortality, cerebrovascular accidents, acute kidney injury (AKI) and requirement for permanent pacemaker (PPM) implantation to be 8.4%, 2.8%, 14.4%, and 13.4%, respectively. Aggregated survival at 1-, 2-, 3-, 5- and 7-year were 83%, 75%, 65%, 48% and 28%, respectively.

CONCLUSIONS

The present systematic review identified acceptable long-term survival results for TAVI procedures in an elderly population. Extended follow-up is required to assess long-term outcomes following TAVI, particularly before its application is extended into wider population groups.

Comparison of late mortality after transcatheter aortic valve implantation versus surgical aortic valve replacement: Insights from a meta-analysis

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) has shown non-inferior late mortality in severe aortic stenosis (AS) patients in intermediate to inoperable risk for surgery compared to surgical aortic valve replacement (SAVR). Late outcome of TAVI compared to SAVR is crucial as the number of TAVI continues to increase over the last few years.

METHODS

A comprehensive literature search of PUBMED and EMBASE were conducted. Inclusion criteria were that [1] study design was a randomized controlled trial (RCT) or a propensity-score matched (PSM) study: [2] outcomes included >2-year all-cause mortality in both TAVI and SAVR. The random-effects model was utilized to calculate an overall effect size of TAVI compared to SAVR in all-cause mortality. Publication bias was assessed quantitatively with Egger's test.

RESULTS

A total of 14 studies with 6503 (3292 TAVI and 3211 SAVR, respectively) were included in the meta-analysis. There was no difference in late all-cause mortality between TAVI and SAVR (HR 1.17, 95%CI 0.98-1.41, p=0.08, I²=61%). The sub-group analysis of all-cause mortality of RCT (HR 0.93 95%CI 0.78-1.10, p=0.38, I²=40%) and PSM studies (HR 1.44 95%CI 1.15-1.80, p=0.02, I²=35%) differed significantly (p for subgroup differences=0.002). Meta-regression implicated that increased age and co-existing CAD may be associated with more advantageous effects of TAVI relative to SAVR on reducing late mortality. There was no evidence of significant publication bias (p=0.19 for Egger's test).

CONCLUSIONS

TAVI conferred similar late all-cause mortality compared to SAVR in a meta-analysis of RCT but had worse outcomes in a meta-analysis of PSM.

Causes and temporal trends in procedural deaths after transcatheter aortic valve implantation

BACKGROUND

The causes of procedural deaths after transcatheter aortic valve implantation (TAVI) have been scarcely detailed.

AIMS

To assess these causes and their temporal trends since the beginning of the TAVI era.

METHODS

From October 2006 to April 2014, 601 consecutive high-risk/inoperable patients with severe aortic stenosis underwent TAVI using the Edwards SAPIEN or SAPIEN XT or the Medtronic CoreValve. The transfemoral route was the default approach; the transapical or left subclavian approaches were alternative options. Patients were divided into three tertiles according to the date of the procedure.

RESULTS

Procedural death occurred in 45 patients (7.5%), with a median±standard deviation age of 83±7 years; 23 were men (51%) and the mean logistic EuroSCORE was 26±16%. The main cause of death was heart failure (n=19, 42%), followed by cardiac rupture (n=12, 27%), intensive care complications (n=9, 20%) and vascular complications (n=5, 11%). The mortality rate was higher after transapical than transfemoral TAVI (17% vs. 5%; P<0.001). The mortality rate decreased over time (11.9% in the first tertile, 6.0% in the second and 4.5% in the third [P=0.007]), driven by a reduction in heart failure-related deaths (6.5% in the first tertile vs. 1.5% in the third; P=0.011). Vascular complication-related deaths disappeared in the third tertile. However, there was no decrease in deaths related to cardiac ruptures and intensive care complications.

CONCLUSIONS

The procedural mortality rate of TAVI decreased over time, driven by the decrease in heart failure-related deaths. However, efforts should continue to prevent cardiac ruptures and improve the outcomes of patients requiring intensive care after TAVI.

Transcatheter aortic valve implantation: new hope in the management of valvular heart disease

Severe calcific aortic stenosis is relatively common, and unless treated with valve replacement it carries an adverse prognosis. A large number of patients, however, are denied surgery due to their advanced age or coexistent medical conditions that increase perioperative cardiovascular risks. Transcatheter aortic valve implantation (TAVI), a technique in which a bioprosthetic valve is inserted via a catheter and implanted within the diseased native aortic valve, is a new therapeutic modality for treatment of older patients with severe symptomatic aortic stenosis and other comorbidities, who have an inherently high surgical risk. This review will provide an overview of the pivotal trials in the development of TAVI; while also investigating important complications and limitations of the procedure and evaluating how new valves are being designed and clinically evaluated, with the ultimate goal of reducing potential complications and expanding the use of TAVI to lower-risk patient cohorts.

Percutaneous Closure of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation: A Systematic Review

Paravalvular regurgitation (PVR) remains one of the drawbacks of transcatheter aortic valve implantation (TAVI). Details of percutaneous closure (PCC) of PVR after TAVI remain obscure. We aimed to explore the patient characteristics, procedural details, closure devices used, and outcomes of PCC after TAVI. A systematic search of the MEDLINE/PubMed and Embase databases from January 2002 to September 2015 was conducted. Reports considered to include same patient were excluded and only the studies with largest cohorts were included. A total of 14 studies including 58 patients (61 cases) were included in the study. A balloon-expandable (BE) valve was used more frequently compared with a self-expandable (SE) valve (72.6% vs 27.4%, respectively). The mean success rate was 86.9% (100% and 77.8%, respectively; P = 0.097). The median number of closure devices used was 1 (range, 1-4) and did not differ between SE and BE valves (P = 0.71). Mean time from index procedure to PCC did not differ between SE and BE valves (295 ± 380 days vs 379 ± 353 days; P = 0.71). Seven patients had history of valve-in-valve and 6 patients had procedural success. Among the patients with available follow-up data (94.8%), there were 15 deaths (27.3%). Percutaneous closure of PVR after TAVI had a high success rate in selected patients in both BE and SE valves. The success rate, timing, and number of closure devices were similar between BE and SE valves. However, prognosis remains fairly poor.

[Non-cardiac aspects of aortic stenosis in the elderly: A review]

Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?

Transcatheter Aortic Valve Implantation in Lower-Risk Patients With Aortic Stenosis

Transcatheter aortic valve implantation underwent progressive improvements until it became the default therapy for inoperable patients, and a recommended therapy in high-risk operable patients with symptomatic severe aortic stenosis. In the lower-risk patient strata, a currently costly therapy that still has important complications with questionable durability is competing with the established effective and still-improving surgical replacement. This report tries to weigh the clinical evidence, the recent technical improvements, the durability, and the cost-effectiveness claims supporting the adoption of transcatheter aortic valve implantation in intermediate-low risk patients. The importance of appropriate patients’ risk stratification and a more comprehensive approach to estimate that risk are also emphasized in the present report.