A overview on transcatheter aortic valve implantation

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Transcatheter aortic valve replacement, or TAVI, had a lot of publicity over the past few years. Prior to TAVI, when faced with those elderly patients with multiple co-morbidities, who were really very restricted symptomatically from aortic stenosis, there really wasn’t much choice. But with any new advent, people question every complication. So now, the NEJM has got a few different articles looking at the TAVI situation.

It all started with the PARTNER people, back in 2010. They looked at over 350 patients who were not suitable for surgery, and randomised them to valvuloplasty (standard therapy) vs. TAVI – and the death rate at 1 year was 30.7% with TAVI, and 49.7% with standard therapy. Repeat hospitalisation was also down, but stroke/TIA were slightly higher.

These patients have now been followed up at 2 years, with death rates at 2 years being 42.3% in the TAVI group and 68% in the standard therapy group. Rates of rehospitalisation were now significantly less, and they had a better functional status. The authors here suggest that the mortality benefit after TAVI may be in those without extensive comorbidities.

There was also the PARTNER trial, assigning 699 people to either TAVI or surgical replacement. Death at 1 year there were only 24.2% for TAVI and 26.8% in surgical group. However, the TAVI group again had higher rates of major stroke, almost double at the 1 year mark. Major vascular complications were more frequent, but new AF and major bleeding were down. Importantly, there no was no difference between the groups at 1 year.

The PARTNER investigators now present the two year follow up, with a review of the 699 patients at 25 centres. Now, the rates of death are fairly similar, at 33.9% in the TAVI group and 35% in the surgery group (no statistical difference). Again, strokes at 30 days were up in the TAVI group, but no significant difference after that. Concerningly, paravalvular regurgitation was up in the TAVI group, and this was associated with higher late mortality.

Lastly, we also have the FRANCE-2 registry, a look at all the patients in France who underwent TAVI. Around 3200 patients were involved, with an average age of 82.7. Mortality at 1 year was as high as 24% however, with a 64.5% rate of periprosthetic aortic regurgitation – associated with reduced survival.

Check it all out in the latest New England Journal of Medicine. Also, the latest US guidelines on TAVI/TAVR are over in the resource section.

 

image | valveguru

source | New England Journal of Medicine

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