Transcatheter aortic valve replacement (TAVR) for severe aortic stenosis

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1. The PARTNER B trial found improved 1 and 2 year mortality with TAVR compared to medical treatment for patients with severe symptomatic aortic stenosis who were not candidates for surgical aortic valve replacement (AVR).

2. The PARTNER A trial compared TAVR and AVR in high-risk surgical patients and found no difference in 1 or 2-year mortality, but higher rates of stroke and perivalvular leaks in the TAVR group.

3. A cost analysis of PARTNER B showed a mean cost of $78,542 per hospitalization, corresponding to $50,212 per life-year gained. 

Aortic stenosis is a valvular heart disease that increases in prevalence with age. Without intervention it is lethal, with a mortality of 75% at 3 years after onset of symptoms. Unfortunately, an estimated 30-40% of patients with severe aortic stenosis are denied surgery due to high risk of complications. In 2002, TAVR emerged as a less invasive option for valve repair. Results of the PARTNER B trial evaluating high-risk patients have supported TAVR improving mortality, while the PARTNER A trial for high-risk surgical patients demonstrated similar overall mortality but higher complication rates with TAVR. Complications include increased stroke rate in the periprocedural period and ongoing development of perivalvular leaks, which are associated with later strokes, endocarditis, hemolysis, and ongoing heart failure. TAVR is now undergoing evaluation for intermediate and low risk subgroups in the PARTNER II trial.

Click to read the study in The Journal of Thoracic and Cardiovascular Surgery

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1. The PARTNER B trial found improved 1 and 2 year mortality with TAVR compared to medical treatment for patients with severe symptomatic aortic stenosis who were not candidates for surgical aortic valve replacement (AVR).

2. The PARTNER A trial compared TAVR and AVR in high-risk surgical patients and found no difference in 1 or 2-year mortality, but higher rates of stroke and perivalvular leaks in the TAVR group.

3. A cost analysis of PARTNER B showed a mean cost of $78,542 per hospitalization, corresponding to $50,212 per life-year gained. 

This [randomized controlled] trial divided high risk surgical patients into those with and without transfemoral access, and randomized the transfemoral group to transfemoral TAVR versus AVR, and the group without access to transapical TAVR versus AVR. Among these patients, there was no difference in mortality but higher rates of neurologic events in the TAVR groups. Inoperable patients were randomized to transfemoral TAVR versus optimal medical therapy (those without transfemoral access were excluded). TAVR patients experienced a survival benefit at 1 and 2 years, but increased rates of perivalvular leaks.

In sum: Aortic stenosis is a valvular heart disease that increases in prevalence with age. Without intervention it is lethal, with a mortality of 75% at 3 years after onset of symptoms. Unfortunately, an estimated 30-40% of patients with severe aortic stenosis are denied surgery due to high risk of complications. In 2002, TAVR emerged as a less invasive option for valve repair. Results of the PARTNER B trial evaluating high-risk patients have supported TAVR improving mortality, while the PARTNER A trial for high-risk surgical patients demonstrated similar overall mortality but higher complication rates with TAVR. Complications include increased stroke rate in the periprocedural period and ongoing development of perivalvular leaks, which are associated with later strokes, endocarditis, hemolysis, and ongoing heart failure. TAVR is now undergoing evaluation for intermediate and low risk subgroups in the PARTNER II trial.

Click to read the study in The Journal of Thoracic and Cardiovascular Surgery

By Gina Siddiqui and Allen Ho

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