The Effect of Initiation of a Transcatheter Aortic Valve Replacement Program in the Treatment of Severe Aortic Stenosis

Abstract

We assessed the effect of a transcatheter aortic valve replacement (TAVR) program and Heart Team concept on our approach to severe isolated symptomatic aortic stenosis (AS) with regard to surgical practice, patient selection, perioperative outcomes, 1-year survival, and AVR volume. TAVR program began in August 2011. Patients having isolated surgical AVR between January 2008 and August 2011, when the program began (n = 282, 42 months), were compared with those after the program began until February 2015 (n = 344, surgical AVR and n = 126, TAVR, 42 months). Isolated surgical AVR accounted for 21% of all valve procedures (isolated and concomitant) before and after the TAVR program. However, the volume of all isolated AVR (surgical and transcatheter) increased to 27% of all valve procedures (isolated and concomitant) after the TAVR program implementation. Mean Society Of Thoracic Surgeons (STS)-predicted mortality risk was similar among patients who had surgical AVR pre-TAVR and post-TAVR implementation (2.3% vs 2.1%, P = 0.227), but addition of patients who had TAVR (STS risk = 7.1%) increased STS-predicted risk for all isolated AVR (surgical and transcatheter) procedures (2.3% vs 3.4%, P < 0.001). A similar trend was found for age, including a slight decrease in octogenarians for surgical AVR post-TAVR (18% vs 13%, P = 0.084). Operative mortality for isolated surgical AVR was similar in pre-TAVR and post-TAVR (2.1% vs 1.8%, P = 0.798), as were observed/expected (O/E) ratios (0.91 vs 0.82). For all isolated AVR, O/E ratio was 0.91 pre-TAVR and 0.82 post-TAVR (n = 470), including O/E = 0.79 for patients who had TAVR. No changes were found in proportion of isolated surgical AVR cases or patient risk and outcomes after introduction of TAVR program and Heart Team. However, volume of patients with severe AS treated increased significantly post-TAVR. Our results reflect growing awareness of TAVR availability and accompanying increases in patients referred to our Heart Team for AS treatment.