The thieving cardiologist

File:Elliottccutler.jpg

For a long time now, valve replacement has been firmly within the realm of the surgeons. In fact, the first work on a valve was done in 1923, by the guy above, Elliott Cutler, who was first in his class at Harvard – and went on to replace Harvey Cushing as the Professor of Surgery. He did a mitral valve repair on a 12 year old girl – but similar procedures had a 90% mortality rate and the process was abandoned. 



Nowadays though, cardiologists have slowly been creeping into the valve repair and replacement territory. Balloon valvotomy has been going on for some time, and then fell out of favour, but the recent big change has been the move to percutanous valve replacement – in this case, aortic. 


This study from the New England Journal follows many others (and is in fact a subgroup of the PARTNER trial below), but has the benefit of having a large number (just shy of 700) of patients to compare, across 25 centres. 


The PARTNER study looked at patients with severe aortic stenosis who were too high risk for surgery, and they either got randomised to standard therapy (including the balloon valvotomy) or to getting a transcather aortic valve implanted – and the TAVI had better outcomes. 


This one now follows on from that, looking at the same high risk patients but comparing those who could have had surgery (and did) versus those who had a percutaneous valve.  


The punchline? 1 year survival rates were similar, 24.2% for transcatheter (TC) and 26.8% for surgical, with a non-significant p-value of 0.44. But there are some particular points to be noted here:

  • 30 day mortality
    • 3.4% for TC
    • 6.5% for surgical
  • major stroke at 30 days
    • 3.8% TC
    • 2.1% surgical
  • major stroke at 1 year
    • 5.1% TC
    • 2.4% surgical
  • major vascular complications
    • 11% TC
    • 3.2% surgical
Although surgery had it’s downsides too:
  • major bleeding
    • 9.3% TC
    • 19.5% surgical
  • new onset AF
    • 8.6% TC
    • 16% surgical
Times have changed (certainly since 2000, when you read this article from the current master of cardiology), and in carefully selected patients (older, lots of co-morbidities, poor LV function), a transcatheter approach may be the way to go, although there’s a long road ahead. 

Have a read of the ever changing future of cardiology – and cardiothoracics – here

IMAGE U.S. Army
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