Appropriateness of Transcatheter Aortic Valve Replacement: Insight From the OCEAN-TAVI Registry

Appropriateness of Surgical Aortic Valve Replacement for Severe Aortic Stenosis Is Increasing

BACKGROUND

The adoption of transcatheter aortic valve replacement led to the development of appropriate use criteria (AUC) for transcatheter and surgical aortic valve replacement (SAVR) for aortic stenosis in 2017. This study hypothesized that appropriateness of SAVR improved after publication of AUC.

METHODS

All patients undergoing isolated SAVR for severe aortic stenosis in a regional cardiac surgical quality collaborative were evaluated using data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). After excluding endocarditis and emergency cases, appropriateness of SAVR (rarely appropriate, may be appropriate, or appropriate) was assigned to patients by using established criteria. The relationship of appropriateness with publication of AUC was assessed, as was variation in appropriateness over time and by center.

RESULTS

Of 3035 patients across 17 centers, 106 (3.5%) underwent SAVR for an indication identified as rarely appropriate or may be appropriate. Patients who underwent SAVR for rarely or may be appropriate indications were significantly more likely to experience operative mortality (5.7% vs 1.6%, P = .001) as well as major morbidity (21.7% vs 10.5%, P < .001). Performance of rarely or may be appropriate SAVR significantly decreased over time (slope -0.51%/year, P trend < .001), and it was decreased after the release of the AUC (before release, 3.83% vs after release, 2.06%; P = .036). Substantial interhospital variation in appropriateness was observed (range of may be or rarely appropriate SAVR, 0%-10%).

CONCLUSIONS

The majority of isolated SAVR for aortic stenosis was appropriate according to the 2017 AUC. Appropriateness improved after publication of AUC, and this improvement was associated with a significant reduction of major morbidity and mortality.

Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.

Appropriate Use Criteria for the Management of Aortic Stenosis: Insight From the Japanese Expert Panel

Background

The indication for transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) significantly varies among physicians and institutions.

Objectives

This study aims to develop a set of appropriate use criteria for AS management to assist physicians in decision-making.

Methods

The RAND-modified Delphi panel method was used. A total of >250 common clinical scenarios were identified in terms of whether to perform the intervention for AS and the mode of intervention (surgical aortic valve replacement vs TAVR). Eleven nationally representative expert panelists independently rated the clinical scenario appropriateness on a scale of 1-9, as "appropriate" (7-9), "may be appropriate" (4-6), or "rarely appropriate" (1-3); the median score of the 11 experts was then assigned to an appropriate-use category.

Results

The panel identified 3 factors that were associated with a rarely appropriate rating in terms of performing the intervention: 1) limited life expectancy; 2) frailty; and 3) pseudo-severe AS on dobutamine stress echocardiography. Clinical scenarios that were deemed rarely appropriate for TAVR were also identified: 1) patients with low surgical risk and high TAVR procedural risk; 2) patients with coexistent severe primary mitral regurgitation or rheumatic mitral stenosis; and 3) bicuspid aortic valve that was not suitable for TAVR. Importantly, any TAVRs for patients who were older than 75 years of age were not rated as rarely appropriate.

Conclusions

These appropriate use criteria provide a practical guide for physicians regarding clinical situations commonly encountered in daily practice and elucidates scenarios deemed rarely appropriate that are clinical challenges for TAVR.

Comparison of Cardiovascular Procedure Rates in Patients With Supplementary vs Basic Insurance in Switzerland

Importance

Switzerland's mandatory health insurance provides universal coverage, but residents can opt for supplementary private insurance for nonessential, nonvital amenities. It is debated whether people with supplementary private insurance receive overtreatment due to financial incentives.

Objective

To assess whether incidence rates of cardiovascular procedures in people with supplementary private insurance are higher than in those with basic insurance only.

Design, Setting, and Participants

A population-based weighted cohort comparative effectiveness study, using administrative claims data from Switzerland assessing incidence rates (IRs), was conducted in adults undergoing a nonemergency cardiovascular inpatient procedure from January 1, 2012, to December 31, 2020. Analysis included primary or secondary discharge procedure codes for 1 of the following: percutaneous transluminal coronary angioplasty (PTCA), left atrial appendage (LAA) occlusion, patent foramen ovale (PFO) closure, transcatheter aortic valve replacement (TAVR), mitral valve clip implantation, cardiac pacemaker implantation, and atrial fibrillation/atrial flutter ablation.

Exposures

Supplementary private health insurance.

Main Outcomes and Measures

Incidence rates of cardiovascular procedures between insurance groups calculated by negative binomial regression adjusted by inverse probability weights.

Results

Of 590 919 admissions (median age, 68 years; IQR, 57-77 years), 55.5% male, 15.7% non-Swiss nationality), 70.1% had basic insurance only. Independent of insurance status, IR for all cardiovascular procedures steadily increased over the study years. In general, people with supplementary private insurance received cardiovascular procedures more frequently (IR ratio [IRR], 1.11; 99% CI, 1.10-1.11) than people with basic insurance only. There was also an increase for every procedure: PTCA (IRR, 1.12; 99% CI, 1.12-1.13), LAA closure (IRR, 1.15; 99% CI, 1.13-1.16), mitral valve clip implantation (IRR, 1.08; 99% CI, 1.07-1.09), TAVR (IRR, 1.04; 99% CI, 1.03-1.06), PFO closure (IRR, 1.01; 99% CI, 1.00-1.02), pacemaker implantation (IRR, 1.08; 99% CI, 1.07-1.09), and atrial fibrillation/atrial flutter ablation (IRR, 1.12; 99% CI, 1.11-1.12). Sensitivity analyses, including side procedures, stratification by length of stay, and propensity score matching, suggested robustness of the results.

Conclusions and Relevance

This study found an association between supplementary private insurance and a higher likelihood of receiving nonemergency cardiovascular procedures. Whether this higher rate of procedures in people with supplementary private insurance is based on clinical reasoning or due to financial incentives warrants further exploration.

Transcatheter aortic valve implantation in patients with bicuspid valve morphology: a roadmap towards standardization

Indications for transcatheter aortic valve implantation (TAVI) have expanded in many countries to include patients with aortic stenosis who are at low surgical risk, and a similar expansion to this cohort is anticipated elsewhere in the world, together with an increase in the proportion of patients with bicuspid aortic valve (BAV) morphology as the age of the patients being treated decreases. To date, patients with BAV have been excluded from major randomized trials of TAVI owing to anatomical considerations. As a consequence, BAV has been a relative contraindication to the use of TAVI in international guidelines. Although clinical experience and observational data are accumulating, BAV presents numerous anatomical challenges for successful TAVI, despite advances in device design. Furthermore, in those with BAV, substantial geographical variation exists in patient characteristics, clinical approach and procedural strategy. Therefore, in this Roadmap article, we summarize the existing evidence and provide consensus recommendations from an international group of experts on the application of TAVI in patients with BAV in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients.

A Special Clinical Scenario for Transcatheter Aortic Valve Replacement: "Iatrogenic Double-Outlet" Left Ventricle

A 67-year-old man with a history of chest radiotherapy and severe aortic valve stenosis with calcification of the ascending aortic wall underwent implantation of an apicoaortic conduit from the left ventricular apex to the descending aorta. Eight years later, he presented with progressive exertional dyspnea. Imaging revealed severe native aortic valve insufficiency and calcification, with worsening left ventricular function. We decided to leave the apicoaortic conduit intact and perform transcatheter aortic valve replacement with a balloon-expandable prosthesis. Despite concerns that eliminating the obstruction across the native left ventricular outflow tract might decrease conduit flow and eventually cause graft thrombosis and peripheral embolization, we elected to move forward after a multidisciplinary discussion. The procedure resulted in angiographically and qualitatively similar forward flow across the newly implanted prosthesis and the existing apicoaortic conduit, with no hemodynamic or electrical dysfunction. The patient was discharged from the hospital the next day. At the 1-month follow-up visit, the patient felt well and reported marked functional improvement, with minimal symptoms during moderate to heavy exertion. The stroke volume index across the new bioprosthetic valve was low (13 mL/m2 at 1 mo and 18 mL/m2 at 1 y), suggesting that a substantial amount of blood was still exiting the ventricle through the left ventricle-to-aorta conduit. This report offers some guidance for treating patients with existing apicoaortic conduits and suggests that transcatheter aortic valve replacement is safe and effective if native aortic valve insufficiency develops.

Transcatheter Aortic Valve Replacement in Asia: Present Status and Future Perspectives

Over the last decade, based on evidence from multiple randomized clinical trials, transcatheter aortic valve replacement (TAVR) has become the established treatment for patients with symptomatic severe aortic stenosis. Despite the overwhelming expansion of TAVR in Western countries, the initial uptake and widespread adoption of this procedure have been relatively delayed in Asian countries, owing to the high cost of devices; limited local health and reimbursement policies; and lack of specific training/proctoring program, specialized heart team, or dedicated infrastructure. Furthermore, it has not yet been determined whether there are substantial interracial and ethnic differences in the clinical characteristics, comorbidities, and anatomic features, as well as procedural and long-term outcomes, in patients receiving TAVR. In this review, we provide not only a comprehensive look at the current status and outcomes of TAVR in Asian populations compared with those of Western populations but also a perspective on the future of TAVR in Asia.

A single-center analysis of outcomes, risk factors, and new valves in Asian patients treated with early transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) continues to expand as an optimal treatment in Western countries; however, Asian countries have been slower to adopt this procedure. This research aimed to explore the outcomes and status of early TAVI performed at a single center in Asia, and provide comparative outcomes of the newly designed Chinese valves.

Methods

We enrolled 175 consecutive patients who successfully underwent TAVI from September 2012 to January 2018 at Fuwai Hospital (Beijing, China). After a preliminary assessment of age, we included 109 older patients (≥69 years) who underwent surgical aortic valve replacement (SAVR) during the same period. The primary endpoint was all-cause mortality. The inverse probability of treatment weighting (IPTW) was used to reduce potential bias. Cox regression was used to identify the risk factors of a poor prognosis.

Results

The TAVI cohort had higher rates of all-cause mortality [11.4% vs. 2.4%, hazard ratio (HR): 4.79, 95% confidence interval (CI): 1.47 to 15.57, IPTW-adjusted P=0.009] and permanent pacemaker implantation (PPI; 14.6% vs. 1.6%, HR: 9.98, 95% CI: 2.71 to 36.67, IPTW-adjusted P<0.001) at 3 years than the SAVR cohort. In the multivariable Cox regression analysis based on the entire sample, liver disease was associated with all-cause mortality (HR: 5.080, 95% CI: 1.067 to 24.174, P=0.041). A smoking history was associated with an increased risk of postoperative heart failure (HF) (HR: 4.902, 95% CI: 1.265 to 18.999, P=0.022). Additionally, age (HR: 1.141, 95% CI: 1.010 to 1.288, P=0.034) and diabetes (HR: 7.301, 95% CI: 2.414 to 22.079, P<0.001) were identified as predictors of postoperative stroke. In the new valve subgroups, the 1-year composite endpoints were 38.2% (Venus A), 35.3% (TaurusOne), 34% (J-Valve), and 28% (VitaFlow) (P=0.857).

Conclusions

Not all TAVI procedures had satisfactory outcomes compared with SAVR when initiated. At first, our center faced some challenges in delivering TAVI, and this is probably one of the reasons why the use of TAVI has developed slowly in Asia. Further investigations are needed to explore the underlying factors precluding the rapid expansion of TAVI in Asia.