Patient-centered benefit-risk analysis of transcatheter aortic valve replacement [version 1; peer review: 2 approved with reservations]

• Published in: F1000 research Vol. 8; p. 394
• Main Authors: Marsh, Kevin, Hawken, Natalia, Brookes, Ella, Kuehn, Carrie, Liden, Barry
• Format: Journal Article
• Language: English
• Published: England 2019
• Subjects: patient preference; aortic valve; transcatheter; TAVR; benefit-risk analysis
• ISSN: 2046-1402; 2046-1402
• DOI: 10.12688/f1000research.18796.1

Background: Aortic stenosis (AS) treatments include surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). Choosing between SAVR and TAVR requires patients to trade-off several benefits and risks. The objective of this research was to determine which outcomes associated with TAVR and SAVR patients consider most important, collect quantitative data about how patients weigh these benefits and risks, and evaluate patients' preferences for SAVR or TAVR.
Methods: Patients with aortic stenosis were recruited from advocacy organization databases. An online adapted swing weighting (ASW) method was used to elicit attribute tradeoffs from 93 patients. The ASW exercise consisted of a series of pairwise comparisons of attributes. Survey data were used to estimate the weight that patients put on the AS treatment attributes, which were incorporated into a quantitative benefit-risk analysis (BRA) to evaluate patients' preferences for TAVR and SAVR.
Results: On average, patients put greater value on attributes that favored TAVR than SAVR. The value patients placed on the lower short-term mortality rate, reduced procedural invasiveness, and quicker time to return to normal quality of life associated with TAVR, offset the value they placed on the time over which SAVR has been proven to work. There was substantial heterogeneity in patients' preferences. This was partly explained by age, with differences in preference observed between patients <60 years to those ≥60 years. A Monte Carlo Simulation found that 75.1% of patients prefer TAVR.
Conclusions: Most AS patients are willing to tolerate sizable increases in clinical risk in exchange for the benefits of TAVR, resulting in a large proportion of patients preferring TAVR to SAVR. Further work should be undertaken to characterize the heterogeneity in preferences for AS treatment attributes. Shared decision-making tools based on attributes important to patients can support patients' selection of the procedure that best meets their needs.