90Risk-adjusted comparison of in-hospital outcomes of transcatheter and surgical aortic valve replacement

• Published in: European heart journal Vol. 40; no. Supplement_1
• Main Authors: Stachon, P, Kaier, K K, Heidt, T H, Zehender, M Z, Bode, C B, Von Zur Muehlen, C M
• Format: Journal Article
• Language: English
• Published: Oxford University Press 01-10-2019
• Subjects: Aortic Valve Intervention
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehz747.0019

Abstract
Background
Transcatheter aortic valve replacement (TAVR) is recommended for patients suffering from aortic valve stenosis at increased operative risk or age over 75 years. Beyond that patients with different co-morbidities could profit from TAVR.
Purpose
The present study analyzes in-hospital outcomes of aortic valve replacement procedures in order to identify subgroups of patients in which TAVR might be preferable.
Methods
For all 33,789 isolated transfemoral TAVR and SAVR procedures performed in Germany in 2014 and 2015, co-morbidities and in-hospital outcomes were identified by ICD- and OPS-codes.
Results
Patients undergoing TAVR were older with more co-morbidities and at increased estimated risk (logistic EuroSCORE TAVR: 13.9±10.3%; SAVR: 5.3±4.7%; p<0.001). In order to allow comparison of outcomes after TAVR and SAVR, a covariate and propensity-adjusted analysis was performed in different subgroups. The risk of mortality is significantly lower in patients undergoing TAVR with an age over 80 years (TAVR vs. SAVR 80–84: OR 0.55; p=0.002; ≥85 OR 0.42, p=0.006) and at high operative risk (patients with EuroSCORE >9: OR 0.62, p=0.001). No significant difference in in-hospital mortality occurs between TAVR and SAVR in patients under 80 and intermediate or low risk (<75: OR 0.85; p=0.404; 75–79 OR 0.82, p=0.219; EuroSCORE <4: OR 1.44, p=0.308; EuroSCORE 4–9: OR 0.81, p=0.156). In contrast, patients with advanced renal failure and patients in NYHA-class III/IV had better outcomes after TAVR (GFR<30: OR 0.45, p=0.005; NYHA III/IV: OR 0.72, p=0.015). Female sex, previous CABG, peripheral arterial disease, COPD, pulmonary hypertension, and diabetes were not found to be factors which favor a treatment strategy. Patients undergoing TAVR suffered more often from strokes and acute kidney failure. After risk-adjustment TAVR was associated with a lower risk for acute kidney injuries (OR 0.62, p<0.001). Risk for stroke was similar (OR 1.07, p=0.558). Risk of bleeding (OR 0.17, p<0.001) and requiring prolonged mechanical ventilation (>48h, OR 0.21, p<0.001) was decreased in patients undergoing TAVR. As expected, the TAVR procedure is associated with an increased risk for pacemaker implantations (OR 4.61, p<0.001).
Conclusions
The present study analyzing over 33.000 real-world procedures confirms that TAVR is the safer procedure in clinical practice for patients with severe aortic valve stenosis at increased operative risk, over 80 years, in NYHA-class III/IV, and with renal failure.