Abstract
Transcatheter aortic valve replacement (TAVR) offers a novel treatment option for patients with severe symptomatic aortic valve stenosis, particularly for patients who are unsuitable candidates for surgical intervention. However, high therapeutical costs, socio-economic considerations, and numerous comorbidities make it necessary to target and allocate available resources efficiently. In the present study, we aimed to identify risk factors associated with futile treatment following transfemoral (TF) and transapical (TA) TAVR. Five hundred and thirty-two consecutive patients (82 ± 9 years, female 63%) who underwent TAVR between June 2009 and December 2016 at the Vienna Heart Center Hietzing were retrospectively analyzed to identify predictors of futility, defined as all-cause mortality at one year following the procedure for the overall patient cohort, as well as the TF and TA cohort. Out of 532 patients, 91 (17%) did not survive the first year after TAVR. A multivariate logistic model identified cerebrovascular disease, home oxygen dependency, wheelchair dependency, periinterventional myocardial infarction, and postinterventional renal replacement therapy as the factors independently associated with an increased one-year mortality. Our findings underscore the significance of a precise preinterventional evaluation, as well as illustrating the subtle differences in baseline characteristics in the TF and TA cohort and their impact on one-year mortality.
Highlights
Transcatheter aortic valve replacement (TAVR) has made it possible to treat patients that were deemed high- or extremely high-risk in the context of conventional heart surgery, the central question that still has not been sufficiently explored is whether certain risk factors will preclude the patients from benefiting from the procedure.In the last few years, transcatheter aortic valve replacement (TAVR) has become a mainstay in the treatment of severe symptomatic aortic stenosis, yet optimizing the periinterventional management through adequate patient selection and preventing complications associated with poor outcome remains pivotal
In the last few years, TAVR has become a mainstay in the treatment of severe symptomatic aortic stenosis, yet optimizing the periinterventional management through adequate patient selection and preventing complications associated with poor outcome remains pivotal
It should be questioned whether and to what extent this patient collective is likely to subjectively benefit from an increase in their physical resilience. This finding warrants further studies in this particular patient collective. It is well established in the recent literature that chronic obstructive pulmonary disease (COPD) as a concomitant risk factor does not necessarily lead to a worse outcome after TA-TAVR, our study demonstrated that pronounced pulmonary oxygenation impairment resulting in home oxygen dependence is significantly associated with futile treatment after TA-TAVR [27]
Summary
In the last few years, TAVR has become a mainstay in the treatment of severe symptomatic aortic stenosis, yet optimizing the periinterventional management through adequate patient selection and preventing complications associated with poor outcome remains pivotal. The number of TAVR procedures is expected to keep rising due to the growing elderly population and as a result of an increase in the number of TAVR interventions in the low-risk and intermediate-risk population, as well as the increased number of centers performing the procedures at higher volumes This increase is attributable to the results of the randomized-controlled PARTNER3 and EVOLUT low-risk trials that managed to demonstrate a non-inferiority of TAVR in the low-risk patient collective, with regard to both safety and efficacy [1,2,3,4,5]. Optimizing patient selection and preventing complications associated with a poor outcome will be crucial steps in ensuring the ideal allocation of scarce healthcare resources to patients who are most likely to benefit from their use
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