TAVR vs SAVR for patients with aortic stenosis: long-term outcomes observed

Now that more data is available concerning long-term outcomes of transcatheter aortic valve replacement (TAVR) for treating severe aortic stenosis, researchers compared these to outcomes in patients who underwent surgical aortic valve replacement (SAVR).

SAVR was once considered the gold standard treatment for severe aortic stenosis (AS). SAVR is a major surgery, where an incision is made to access the heart to replace the damaged valve. Since 2011, TAVR has represented an alternative option, whereby a catheter is inserted into an artery to deliver the new valve all without having to surgically open the chest or heart. Typically, as TAVR is the less invasive procedure with a shorter recovery period, it is often the preferred approach for older patients and for individuals classed as a high surgical risk.

Though the short-term outcomes in TAVR have been observed, data on long-term outcomes is now becoming more widely available. Understanding these long-term outcomes will help inform deciding the most appropriate treatment for patients with AS. A meta-analysis was conducted by a cohort of universities from Italy, the US, Azerbaijan and Canada. The study, published in the Journal of the Society for Cardiovascular Angiography and Interventions (JSCAI), compared randomized trials that observed long-term outcomes in patients with AS who were treated with either TAVR or SAVR. The authors also sought to observe differences between types of valves used in TAVR, self-expanding and balloon-expandable. The results from over 7500 patients across seven trials were examined.

Death and disabling stroke were considered the two most important long-term outcomes but no significant difference was observed between TAVR and SAVR. There was also no variation across surgical risk profiles (low, intermediate and high). However, when comparing the valve types used in TAVR, self-expanding TAVR yielded a lower risk of death or disabling stroke compared to balloon-expandable TAVR and also SAVR.

Though death and stroke rates were similar between TAVR and SAVR, there was a higher level of pacemaker implantation and moderate-to-severe paravalvular leaks in patients following TAVR, specifically when self-expanding valves were used. However, in addition to lower death and stroke risk, self-expandable TAVR also demonstrated lower valve thrombosis and lower valve pressure gradients. The lower risk of death and stroke in self-expandable TAVR may be attributed to the lower risk of valve thrombosis. Though valve thrombosis was lower in self-expandable TAVR, the authors considered it an emerging issue, which needs monitoring long-term as the types of thrombosis observed may lead to valve degeneration and possibly increase the risk of cerebrovascular events.

Co-author of the study, Eliano Pio Navarese, Head of Clinical Experimental Cardiology and Associate Professor at the University of Sassari (Sassari, Italy) commented: “[The study] represents the largest scale analysis so far available comparing longer-term percutaneous devices for aortic valve replacement versus surgery. Our findings support the comparable long-term safety and efficacy of TAVR, as well as raise important considerations for valve type selection, particularly when we are dealing with longer-term valve durability and pacemaker implantation.” The overall understanding of long-term outcomes will help clinicians determine risk levels for different patients and which valve types to use.