Percutaneous aortic valve replacement – patient selection is key

Studies among elderly populations demonstrate that conventional aortic valve replacement (AVR) remains the gold standard for the treatment of critical aortic stenosis compared to medical therapy. However, among populations deemed too high-risk for conventional surgery, or among those who decline surgical intervention, percutaneous procedures such as transcatheter aortic valve implantation (TAVI) may be an option. Consequently, patients who were at one time considered inappropriate for intervention are now being referred for surgical opinions more frequently.

Dewey et al. described the management and outcome of 105 patients referred to their centre (Medical City Dallas Hospital, USA) for consideration of TAVI. Patients had either previously been refused conventional surgical intervention or were considered to be at extreme risk with standard AVR.  Following multidisciplinary team assessment 52 (49.5%) patients received medical management (MM), 16 (15.2%) conventional AVR, 21 (20%) TAVI and 16 (15.2%) balloon aortic valvuloplasty (BAV). Significant differences were observed among the groups with regards to predicted risk of mortality score (using the Society of Thoracic Surgeons predicted risk of mortality); BAV, 11.8% ± 6.5%; MM, 11.3% ± 6.7%; TAVI, 10.9% ± 3.5%; AVR, 6.3% ± 3.5%. All cause 30 day mortality was 1 of 16 patients (6.3%) for AVR, 2 of 21 (9.5%) with TAVI, 2 of 16 (12.5%) for BAV, and 7 of 52 (13.5%) for the MM cohort. Overall mortality during mean follow up of 159 ± 147 days was 42.3% (22 of 52 patients) for MM, 19.1% (4 of 21 patients) for TAVI, 12.5% (2 of 16 patients) for AVR, and 37.5% (6 of 16 patients) for BAV.

The decision to offer surgery to the elderly and high-risk patient populations remains complex. Evaluation of these unique populations can be improved by a multidisciplinary team approach involving surgeons and cardiologists. This study shows that TAVI and AVR can be performed in appropriately selected high-risk patients with good early and long-term outcome.

  • Dewey TM, Brown DL, Das TS et al.  High-Risk Patients Referred for Transcatheter Aortic Valve Implantation: Management and Outcomes.   Ann Thorac Surg 2008;86:1450-7

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