Quality of Life Measures in Aortic Stenosis Research: A Narrative Review

BACKGROUND

Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS.

SUMMARY

We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ).

KEY MESSAGES

There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Uncertainty in model-based treatment decision support: Applied to aortic valve stenosis

Patient outcome in trans-aortic valve implantation (TAVI) therapy partly relies on a patient's haemodynamic properties that cannot be determined from current diagnostic methods alone. In this study, we predict changes in haemodynamic parameters (as a part of patient outcome) after valve replacement treatment in aortic stenosis patients. A framework to incorporate uncertainty in patient-specific model predictions for decision support is presented. A 0D lumped parameter model including the left ventricle, a stenotic valve and systemic circulatory system has been developed, based on models published earlier. The unscented Kalman filter (UKF) is used to optimize model input parameters to fit measured data pre-intervention. After optimization, the valve treatment is simulated by significantly reducing valve resistance. Uncertain model parameters are then propagated using a polynomial chaos expansion approach. To test the proposed framework, three in silico test cases are developed with clinically feasible measurements. Quality and availability of simulated measured patient data are decreased in each case. The UKF approach is compared to a Monte Carlo Markov Chain (MCMC) approach, a well-known approach in modelling predictions with uncertainty. Both methods show increased confidence intervals as measurement quality decreases. By considering three in silico test-cases we were able to show that the proposed framework is able to incorporate optimization uncertainty in model predictions and is faster and the MCMC approach, although it is more sensitive to noise in flow measurements. To conclude, this work shows that the proposed framework is ready to be applied to real patient data.

Effects of Transcatheter Aortic Valve Implantation on Frailty and Quality of Life

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an effective alternative to surgical valve replacement in high-risk patients with severe aortic stenosis. Although measures of frailty have been used to attempt to predict outcomes in this population, few studies have demonstrated changes in these measures.

METHODS

We performed a prospective, observational study of 171 patients undergoing TAVI, of whom 44 had maximal follow-up of 1 month and 50 had maximal follow-up of 1 year. Quality of life was assessed using the Minnesota Living With Heart Failure Questionnaire, Katz Index of Independence in Activities of Daily Living questionnaire, and patient perception of overall well-being. Frailty was measured using the 10-m walk test and handgrip strength testing.

RESULTS

In the overall cohort, participants demonstrated improvements in quality of life metrics, but deterioration in 10-m walk test and handgrip at 1 month. These trends continued at 1 year. However, patients in the lowest quintile of handgrip and 10-m walk test demonstrated a trend of improvements in these metrics during follow-up.

CONCLUSIONS

Despite improvements in quality of life after TAVI, no improvements in frailty were observed in patients at 1 year.

Transfemoral versus transapical approach for transcatheter aortic valve implantation: hospital outcome and risk factor analysis

Background

Transcatheter aortic valve implantation is indicated in high-risk patients with aortic stenosis. We compared the clinical outcome of 180 consecutive patients who underwent transapical (TA) and transfemoral (TF) procedures in a single centre.

Methods

Ninety consecutive TA (TA-group) and 90 consecutive TF (TF-group) were performed from 2009 to 2014. Clinical variables were prospectively collected and retrospectively analysed for hospital outcomes and to identify risk factors for hospital mortality, vascular complications and stroke.

Results

Mean age was 80 ± 8.5 and 83 ± 8.4 years, in the TA and TF-group, respectively. TA-group presented higher prevalence of comorbidities: more vascular disease (79% vs 22%, p < 0.001), chronic pulmonary disease (32% vs 10%, p < 0.001), previous vascular surgery (14% vs 4%, p = 0.039), coronary disease (60% vs 40%, p = 0.007), and previous cardiac surgery (28% vs 17%, p = 0.073). Logistic Euroscore was 36 ± 15% in the TA-group and 25 ± 14% in the TF-group (p < 0.001), but hospital mortality was similar (TA:9%, TF:10%, p = 0.799). Access-related vascular complications occurred more often in transfemoral patients (TA:3%, TF:11%, p = 0.081) while major bleeding (TA:3%, TF:4%, p = 1) and stroke (TA:2%, TF:3%, p = 1) were equally distributed. Postoperative renal failure and dialysis were associated with impaired neurological outcome (p = 0.035 and p = 0.020, respectively). Mild to severe paravalvular leak was more prevalent in transfemoral patients (TA:5%, TF:25%, p < 0.001).

Conclusions

In our experience, the TA and TF-group presented different risk profiles but mortality rate and adverse neurological outcome had a similar incidence. The transfemoral approach carried more vascular complications and paravalvular leaks but last-generation devices will improve this outcome.

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.

[Transcatheter aortic valve implantation for aortic stenosis. Initial experience]

BACKGROUND

Aortic stenosis is a frequent disease in the elderly, and is associated with other systemic pathologies that may contraindicate the surgical procedure. Another option for these patients is percutaneous aortic valve implantation, which is less invasive. We present our initial experience with this procedure.

MATERIAL AND METHODS

Patients with aortic stenosis were included once selection criteria were accomplished. Under general anaesthesia and echocardiographic and fluosocopic control, a transcatheter aortic valve was implanted following s valvuloplasty. Once concluded the procedure, angiographic and pressure control was realized in order to confirm the valve function.

RESULTS

Between November 2014 and May 2015, 6 patients were treated (4 males and 2 females), with a mean age of 78.83±5.66 years-old. The preoperative transvalvular gradient was 90.16±28.53mmHg and posterior to valve implant was 3.33±2.92mmHg (P<.05). Two patients had concomitant coronary artery disease which had been treated previously. One patient presented with acute right coronary artery occlusion which was immediately treated. However due to previous renal failure, postoperative sepsis and respiratory failure, the patient died one month later.

CONCLUSION

It was concluded that our preliminary results showed that in selected patients percutaneous aortic valve implantation is a safe procedure with clinical improvement for treated patients.

Patients' self-reported function, symptoms and health-related quality of life before and 6 months after transcatheter aortic valve implantation and surgical aortic valve replacement

BACKGROUND

Aortic stenosis is the most common valve disease in western countries and has poor prognosis without treatment. Surgical aortic valve replacement (SAVR) is the gold standard, and transcatheter aortic valve implantation (TAVI) is a new method that is used in high-risk patients who are denied surgery. The purpose of treatment is not only to save life, but also to reduce symptoms and increase health-related quality of life (HRQoL).

OBJECTIVE

The aim of this study was to describe patients' self-reported outcomes in terms of physical function, symptoms, dependence, HRQoL, and cognitive function after TAVI and SAVR.

METHODS

All patients treated with TAVI during 1 year ( n = 24) and age-matched patients treated with SAVR ( n = 24) were included. Data were collected on the day before and at 6 months after treatment using structural questionnaires.

RESULTS

Self-rated function was low before treatment and increased at follow-up. A quarter of all patients reported syncope at baseline, and none reported this at follow-up. Breathlessness was reported by all patients to be the most limiting cardiac symptom, but the TAVI patients reported more severe symptoms. At 6 months' follow-up, symptoms were reduced, but breathlessness and fatigue were still common, especially in the TAVI group. HRQoL, which was very low in the TAVI group at baseline, increased in all dimensions except social function.

CONCLUSION

We found no change in cognitive function or dependence at follow-up. There was no difference in the size of improvement between groups. The results could be helpful when informing future patients in order to give them realistic expectations.

Early and late changes in quality of life following transcatheter aortic valve implantation using the transfemoral and transapical approaches

AIMS

To evaluate the effects of access route upon clinical results and quality of life (QoL) in patients undergoing either transfemoral (TF-TAVI) or transapical balloon-expandable transcatheter aortic valve implantation (TA-TAVI) in the real world.

METHODS AND RESULTS

A prospective analysis was performed upon 264 consecutive patients receiving TF-TAVI or TA-TAVI. QoL was assessed using the EQ-5D questionnaire. At baseline, TA-TAVI patients reported significantly more problems in mobility, self-care, usual activities and lower overall health status domains (p<0.01 for all). At 30 days, the TF-TAVI group reported fewer problems with usual activity (p=0.01) and pain/discomfort (p<0.01), and higher EQ-5D index and visual analogue scale (VAS) (p=0.01 and p<0.01, respectively) than the TA-TAVI group. Nevertheless, the absolute improvements (ΔEQ-5D index and ΔEQ-5D VAS) were larger in the TA-TAVI group, with most dramatically marked QoL absolute improvements (p<0.01 and p=0.02, respectively). By one year, notwithstanding higher all-cause mortality in the sicker TA-TAVI group, there were no differences between groups in any EQ-5D domain. Indeed, surviving TA-TAVI group's greater absolute improvements remained (p<0.01).

CONCLUSIONS

QoL is greater at the earlier time point of 30 days in the TF-TAVI cohort but equatable by one year. However, the magnitude of improvement in QoL is greater in the TA-TAVI patients at both 30 days and one year.

Impact of DRG billing system on health budget consumption in percutaneous treatment of mitral valve regurgitation in heart failure

OBJECTIVE

Percutaneous correction of mitral regurgitation (MR) by MitraClip (Abbot Vascular, Abbot Park, Illinois, USA) trans-catheter procedure (MTP) may represent a treatment for an unmet need in heart failure (HF), but with a largely unclear economic impact.

RESEARCH DESIGN AND METHODS

This study estimated the economic impact of the MTP in common practice using the disease-related group (DRG) billing system, duration and average cost per day of hospitalization as main drivers. Life expectancy was estimated based on the Seattle Heart Failure Model. Quality-of-life was derived by standard questionnaires to compute quality-adjusted year-life costs.

RESULTS

Over 5535 discharges between 2012-2013, HF as DRG 127 was the main diagnosis in 20%, yielding a reimbursement of €3052.00/case; among the DRG 127, MR by ICD-9 coding was found in 12%. Duration of hospitalization was longer for DRG 127 with than without MR (9 vs 8 days, p < 0.05). HF in-hospital management generated most frequently deficit, in particular in the presence of MR, due to the high costs of hospitalization, higher than reimbursement. MTP to treat MR allowed DRG 104-related reimbursement of €24,675.00. In a cohort of 34 HF patients treated for MR by MTP, the global budget consumption was 2-fold higher compared to that simulated for those cases medically managed at 2-year follow-up. Extrapolated cost per quality-adjusted-life-years (QALY) for MTP at year-2 follow-up was ∼ €16,300.

CONCLUSIONS

Based on DRG and hospitalization costing estimates, MTP might be cost-effective in selected HF patients with MR suitable for such a specific treatment, granted that those patients have a clinical profile predicting high likelihood of post-procedural clinical stability in sufficiently long follow-up.

Cardiac rehabilitation and mid-term follow-up after transcatheter aortic valve implantation

BACKGROUND

Evaluation of patient outcomes following transcatheter aortic valve implantation (TAVI) has usually been based on survival and clinical improvement. Studies on quality of life are limited, and data from comprehensive assessments after the procedure are lacking.

METHODS

Sixty patients referred for cardiac rehabilitation after TAVI underwent in-hospital and after-discharge multidimensional assessments to evaluate clinical, functional, and nutritional statuses, degree of autonomy, cognitive impairment, depression and quality of life.

RESULTS

On admission to rehabilitation, approximately half of the patients had severe functional impairment and dependence for basic activities of daily living. During their hospital stay, one-third of the patients suffered significant clinical complications and two had to be transferred to the implantation center. Despite this, the overall outcome was very good. All of the remaining patients were clinically stable at discharge and functional status, autonomy and quality of life were improved in most. During a mean follow-up of 540 days (range: 192-738 days), five patients died from noncardiac causes, three were hospitalized for cardiac events, and nine for non cardiac reasons. Functional status and autonomy remained satisfactory in the majority of patients and most continued to live independently.

CONCLUSIONS

Patients referred for rehabilitation after TAVI are often very frail, with a high grade of functional impairment, dependence on others and high risk of clinical complications. During a rehabilitation programme, based on a multidimensional assessment and intervention, most patients showed significant improvement in functional status, quality of life, and autonomy, which remained stable in the majority of subjects during mid-term follow-up.

Advanced age and the clinical outcomes of transcatheter aortic valve implantation

Aortic valve stenosis (AS) is common in the elderly. Although surgical replacement of the valve has been the gold standard of management, many patients have been excluded from surgery because they were very old, frail, or had co-morbidities that increased operative risks. In the last decade, transcatheter aortic valve implantation (TAVI) has emerged as a new treatment option suitable for these patients. This article reviews the available literature on the role of TAVI in elderly patients with severe aortic stenosis. Published studies showed that elderly individuals who underwent TAVI experienced better in-hospital recovery, and similar short and mid-term mortality compared to those underwent surgical treatment of AS. However, long-term outcomes of TAVI in elderly patients are still unknown. The available data in the literature on the effect of advanced age on clinical outcomes of TAVI are limited, but the data that are available suggest that TAVI is a beneficial and tolerable procedure in very old patients. Some of the expected complications after TAVI are reported more in the oldest patients such as vascular injures. Other complications were comparable in TAVI patients regardless of their age group. However, very old patients may need closer monitoring to avoid further morbidities and mortality.

Beyond adding years to life: health-related quality-of-life and functional outcomes in patients with severe aortic valve stenosis at high surgical risk undergoing transcatheter aortic valve replacement

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR.

Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

Functional status and quality of life after transcatheter aortic valve replacement: a systematic review

BACKGROUND

The functional and quality-of-life benefits of transcatheter aortic valve replacement (TAVR) have not been established.

PURPOSE

To evaluate the changes in functional status and quality of life after TAVR.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1 January 2002 to 30 September 2013.

STUDY SELECTION

Studies of TAVR that reported the New York Heart Association (NYHA) class, Short Form-12/36 Health Survey physical and mental component summary (points), or other measures of functional status.

DATA EXTRACTION

Two reviewers independently extracted the mean change (follow-up minus baseline) in primary outcomes. Because of substantial heterogeneity, data were not pooled; the range of mean change was summarized.

DATA SYNTHESIS

We identified 60 observational studies (56 pre–post comparison and 4 head-to-head comparative studies) and 2 randomized, controlled trials (11 205 patients). Most studies showed a clinically important decrease in NYHA class at 6 to 11 months (range, -0.8 to -2.1 classes) and 12 to 23 months (range, -0.8 to -2.1 classes). The improvement in the Short Form-12/36 Health Survey physical component score was clinically important over 12 months (range, 4.9 to 26.9 points), and the change in mental component score was smaller (range, 1.0 to 8.9 points).Clinically important improvements were seen in other disease-specific measures but were less consistently seen in general health measures.

LIMITATIONS

Comparative evidence is limited by few head-to-head studies. Survivor bias may have overestimated the benefits.

CONCLUSION

Transcatheter aortic valve replacement provides clinically important benefits in physical function and disease-specific measures of quality of life but modest benefits in psychological and general health measures. More comparative studies on functional status and quality of life are needed for informed treatment decision making.

Clinical presentation and outcomes after transcatheter aortic valve implantation in patients with low flow/low gradient severe aortic stenosis

OBJECTIVES

To identify predictors of mortality, functional status, and hemodynamical changes of patients undergoing transcatheter aortic valve implantation (TAVI) for low flow/low gradient aortic stenosis (LF/LG AS).

BACKGROUND

There is little published data regarding the outcomes of patients with LF/LG AS following TAVI.

METHODS

Sixty-eight patients with severe AS, left ventricular dysfunction (ejection fraction [EF] <35%) and low flow (LF) AS underwent TAVI. Patients were stratified according to the aortic mean pressure gradient (low gradient [LG]; with Pmean ≤40 mm Hg and high gradient [HG]: Pmean >40 mm Hg). The baseline parameters and clinical outcomes were subsequently compared among the two groups. Cox proportional hazards were used to identify predictors of 6-month mortality.

RESULTS

There were 38 patients in the LG group and 30 patients in the HG group. There were no significant difference in 30-day mortality between the two groups. The 6-month and 1-year mortality, however, was 3.8-fold and 2.8-fold higher in the LG group than in the HG group (37.8% vs. 10.3%, P = 0.01 and 37.8% vs. 13.3%, respectively, P = 0.01). Univariable predictors for 6-month mortality were: STS Score, aortic valve area, and aortic mean pressure gradient. However, only STS Score (HR 1.08, 1.04-1.12, P < 0.001) remained as independent predictor in the multivariable analysis. Six months after TAVI, hemodynamical (EF > 50%) and clinical (NYHA class I) improvements were shown in both HG and LG groups.

CONCLUSIONS

LF/LG AS does not influence procedural mortality after TAVI but exhibits a strong impact on 6-month and 1-year mortality. The survivors, however, exhibit considerable hemodynamical and clinical improvements. Therefore, risk stratification and TAVI benefit should be weighted in every patient with LF/LG AS.

The 2011-12 pilot European Sentinel Registry of Transcatheter Aortic Valve Implantation: in-hospital results in 4,571 patients

AIMS

The aim of this prospective multinational registry is to assess and identify predictors of in-hospital outcome and complications of contemporary TAVI practice.

METHODS AND RESULTS

The Transcatheter Valve Treatment Sentinel Pilot Registry is a prospective independent consecutive collection of individual patient data entered into a web-based case record form (CRF) or transferred from compatible national registries. A total of 4,571 patients underwent TAVI between January 2011 and May 2012 in 137 centres of 10 European countries. Average age was 81.4±7.1 years with equal representation of the two sexes. Logistic EuroSCORE (20.2±13.3), access site (femoral approach: 74.2%), type of anaesthesia and duration of hospital stay (9.3±8.1 days) showed wide variations among the participating countries. In-hospital mortality (7.4%), stroke (1.8%), myocardial infarction (0.9%), major vascular complications (3.1%) were similar in the SAPIEN XT and CoreValve (p=0.15). Mortality was lower in transfemoral (5.9%) than in transapical (12.8%) and other access routes (9.7%; p<0.01). Advanced age, high logistic EuroSCORE, pre-procedural ≥grade 2 mitral regurgitation and deployment failure predicted higher mortality at multivariate analysis.

CONCLUSIONS

Increased operator experience and the refinement of valve types and delivery catheters may explain the lower rate of mortality, stroke and vascular complications than in historical studies and registries.

Transcatheter aortic valve replacement in patients with severe aortic stenosis who are at high risk for surgical complications: summary assessment of the California Technology Assessment Forum

BACKGROUND

The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications.

METHODS AND RESULTS

In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence.

CONCLUSIONS

TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and postoperative care to preserve and improve on the results attained in the Placement of Aortic Transcatheter Valve trial. Specialty societies are collaborating to ensure that this happens in a rational and comprehensive manner.

Left ventricular reverse remodeling after transcatheter aortic valve implantation: a cardiovascular magnetic resonance study

BACKGROUND

In patients with severe aortic stenosis, left ventricular hypertrophy is associated with increased myocardial stiffness and dysfunction linked to cardiac morbidity and mortality. We aimed at systematically investigating the degree of left ventricular mass regression and changes in left ventricular function six months after transcatheter aortic valve implantation (TAVI) by cardiovascular magnetic resonance (CMR).

METHODS

Left ventricular mass indexed to body surface area (LVMi), end diastolic volume indexed to body surface area (LVEDVi), left ventricular ejection fraction (LVEF) and stroke volume (SV) were investigated by CMR before and six months after TAVI in patients with severe aortic stenosis and contraindications for surgical aortic valve replacement.

RESULTS

Twenty-sevent patients had paired CMR at baseline and at 6-month follow-up (N=27), with a mean age of 80.7±5.2 years. LVMi decreased from 84.5±25.2 g/m2 at baseline to 69.4±18.4 g/m2 at six months follow-up (P<0.001). LVEDVi (87.2±30.1 ml /m2vs 86.4±22.3 ml/m2; P=0.84), LVEF (61.5±14.5% vs 65.1±7.2%, P=0.08) and SV (89.2±22 ml vs 94.7±26.5 ml; P=0.25) did not change significantly.

CONCLUSIONS

Based on CMR, significant left ventricular reverse remodeling occurs six months after TAVI.

Transcatheter aortic valve implantation: restoring the qualities of life in old age

Transcatheter aortic valve implantation (TAVI) is a tremendous therapeutic advance for patients with severe aortic stenosis and high-surgical risk. Since TAVI-treated patients are elderly with multiple co-existing conditions, limited life expectancy and disproportionate health-care expenditures, the aspect of the health-related quality of life (HRQoL) benefits becomes of fundamental importance. Based on recent evidence, TAVI appears to improve significantly HRQoL measures compared with optimal standard care, which are restored to age-adjusted population norms over time.

Conventional aortic valve replacement in transcatheter aortic valve implantation candidates: a 5-year experience

BACKGROUND

Patient selection for transcatheter aortic valve implantation (TAVI) remains highly controversial. Some screened patients subsequently undergo conventional aortic valve replacement (AVR) because they are unsuitable TAVI candidates. This study examined the indications and outcomes for these patients, thereby determining the efficacy of the screening process.

METHODS

Between January 2006 and December 2010, 79 consecutive patients (49% men), aged older than 75 years with high surgical risk, were screened for TAVI, but subsequently underwent conventional AVR through a partial or complete sternotomy. The indications, demographics, and outcomes of this cohort were studied.

RESULTS

Mean age was 80.4±3.6 years. Mean left ventricular ejection fraction was 0.55±0.16, and the mean logistic European System for Cardiac Operative Risk Evaluation was 13%±7%. Of the 79 patients, 6 (7.6%) had prior cardiac surgical procedures. Indications for TAVI denial after patient evaluations were a large annulus in 31 (39%), acceptable risk profile for AVR in 24 (30%), need for urgent operation in 11 (14%), and concomitant cardiovascular pathology in 5 (6%). Mean cross-clamp time was 55±14 minutes, and cardiopulmonary bypass time was 81±21 minutes. Concomitant procedures included a Maze in 12 patients (15%). Postoperative morbidity included permanent stroke in 2 (2.5%), respiratory failure in 9 (11%), and pacemaker implantation in 2 (2.5%). Hospital mortality was 1.3% (1 of 79). Cumulative survival at 6, 12, and 36 months was 88.5%, 87.1% and 72.7%, respectively.

CONCLUSIONS

Our existing patient evaluation process accurately defines an acceptable risk cohort for conventional AVR. The late mortality rate reflects the advanced age and comorbidities of this cohort. The data suggest that overzealous widening of TAVI inclusion criteria may be inappropriate.

One-year results of health-related quality of life among patients undergoing transcatheter aortic valve implantation

Recently, it has been demonstrated that transcatheter aortic valve implantation (TAVI) can result in significant improvement in patients' quality of life (QOL) in the short term. At present, however, little is known about the long-term improvements in QOL after TAVI. Thus, our aim was to prospectively assess the 1-year QOL outcome of patients undergoing TAVI. We performed a prospective analysis of 186 patients with symptomatic severe aortic valve stenosis ineligible for conventional aortic valve replacement, who underwent TAVI with either the Medtronic CoreValve or Edwards Sapien device. A total of 106 patients completed the 1-year follow-up protocol. The QOL was measured using the Medical Outcomes Study 36-item short-form health survey questionnaire at baseline and at 3 months and 1 year of follow-up. At 1 year of follow-up, significant improvements in the Medical Outcomes Study 36-item short-form health survey questionnaire scores for physical functioning (baseline 34.6 ± 2.3 vs 1 year of follow-up 45.6 ± 2.7; p <0.001), role physical (20 ± 3.0 vs 34.2 ± 4.4; p <0.001), bodily pain (59.9 ± 3 vs 70 ± 2.7; p <0.01), general health (47.3 ± 1.5 vs 55.2 ± 2.1, p <0.001), vitality (35.9 ± 2 vs 48.5 ± 2; p <0.001), and mental health (62.2 ± 2.2 vs 67.3 ± 1.8; p <0.05) were observed compared to baseline. No significant improvement could be detected for social functioning (75.4 ± 2.5 vs 76.5 ± 2.6; p = 0.79) and role emotional (61.1 ± 4.3 vs 66.5 ± 4.7; p = 0.29). At 1 year of follow-up, the various physical and mental scores were comparable to an age-matched standard population. In conclusion, the present study has demonstrated that TAVI can improve the QOL status of high-surgical risk patients with severe aortic valve stenosis that can be maintained for ≤1 year postproceduraly in survivors. Although the mental subscales improved slightly, the mental component summary score failed to reach statistical significance in our study population.

Transcatheter aortic-valve replacement for inoperable severe aortic stenosis

BACKGROUND

Transcatheter aortic-valve replacement (TAVR) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The outcomes beyond 1 year in such patients are not known.

METHODS

We randomly assigned patients to transfemoral TAVR or to standard therapy (which often included balloon aortic valvuloplasty). Data on 2-year outcomes were analyzed.

RESULTS

A total of 358 patients underwent randomization at 21 centers. The rates of death at 2 years were 43.3% in the TAVR group and 68.0% in the standard-therapy group (P<0.001), and the corresponding rates of cardiac death were 31.0% and 62.4% (P<0.001). The survival advantage associated with TAVR that was seen at 1 year remained significant among patients who survived beyond the first year (hazard ratio, 0.58; 95% confidence interval [CI], 0.36 to 0.92; P=0.02 with the use of the log-rank test). The rate of stroke was higher after TAVR than with standard therapy (13.8% vs. 5.5%, P=0.01), owing, in the first 30 days, to the occurrence of more ischemic events in the TAVR group (6.7% vs. 1.7%, P=0.02) and, beyond 30 days, to the occurrence of more hemorrhagic strokes in the TAVR group (2.2% vs. 0.6%, P=0.16). At 2 years, the rate of rehospitalization was 35.0% in the TAVR group and 72.5% in the standard-therapy group (P<0.001). TAVR, as compared with standard therapy, was also associated with improved functional status (P<0.001). The data suggest that the mortality benefit after TAVR may be limited to patients who do not have extensive coexisting conditions. Echocardiographic analysis showed a sustained increase in aortic-valve area and a decrease in aortic-valve gradient, with no worsening of paravalvular aortic regurgitation.

CONCLUSIONS

Among appropriately selected patients with severe aortic stenosis who were not suitable candidates for surgery, TAVR reduced the rates of death and hospitalization, with a decrease in symptoms and an improvement in valve hemodynamics that were sustained at 2 years of follow-up. The presence of extensive coexisting conditions may attenuate the survival benefit of TAVR. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.).