TAVR decreases OS in patients with severe aortic stenosis

SEATTLE — Overall survival of patients with severe aortic stenosis assigned transcatheter aortic valve replacement decreased drastically 24 months after surgery compared with patients who underwent surgical aortic valve replacement or sutureless valves.

Perspective from Marc Ruel, MD, MPH, FRCSC; Michael J. Reardon, MD

“Our data suggested that patients with severe aortic stenosis and an intermediate-risk profile with TAVR showed a [significantly] worse outcome when compared [with] conventional surgery,” Claudio Muneretto, MD, of the University of Brescia Medical School in Italy, said during his presentation at the American Association for Thoracic Surgery Annual Meeting.

Muneretto and colleagues conducted a propensity-score analysis of 991 consecutive patients with severe aortic stenosis and intermediate-high risk profile to determine the clinical outcomes of patients treated either by surgical aortic valve replacement (SAVR), sutureless valve implantation or transcatheter aortic valve replacement (TAVR).

Analysis was performed based on the therapeutic strategy of 204 patients in each surgical group.

Researchers assessed mortality at 30 days after surgery and OS at 24-month follow-up.

Patients in the TAVR group had a greater mortality rate (9.8%) at 30 days than patients who underwent SAVR (3.4%) or sutureless valves (5.8%; P = .005). Likewise, the OS rate at 24-month follow-up was lower among patients in the TAVR group (79.5%) compared with SAVR (91.3%) or sutureless valves (94.9%; P = .001).

Multivariate Cox regression analysis also identified TAVR as an independent risk factor for overall mortality (OR= 2.5, 95% CI, 1.1-4-2).

Muneretto said the use of TAVR should be carefully weighed in this population.

“The deliberate use of TAVR in this specific subset of patients should be restricted in further, independent controlled-randomized trials,” he said. – by Ryan McDonald

Reference:

Muneretto C, et al. Plenary 6. Presented at: the American Association for Thoracic Surgery Annual Meeting; April 25-29, 2015; Seattle.

Disclosure: Muneretto reports no relevant financial disclosures.

Perspective

Marc Ruel, MD, MPH, FRCSC

I think we have to be careful with the conclusions that [Muneretto and colleagues] derive from the paper. Propensity matching in no way can account for bias at the inception. You can readily remove confounders from a series, but bias cannot be removed by any form of postop analysis.

I think we have to take it with a grain of salt. For everything else being equal, the surgical AVR patient is usually healthier, and the TAVR patient is usually sicker.

This is biased at the inception, and I think despite controlling for everything, this bias will be variable and show up especially in regard to survival as [the researchers] have shown in [their] study.

Marc Ruel, MD, MPH, FRCSC

University of Ottawa

Disclosures: Ruel reports no relevant financial disclosures.

Perspective

Michael J. Reardon, MD

I would agree with [the researchers’] concept that we really should move down to the next layer of randomized trials. But I think we really need to be careful as surgeons about thinking that we’ve beat them with this trial.

Michael J. Reardon, MD

Houston Methodist Hospital

Disclosures: Reardon reports no relevant financial disclosures.