The advent of transcatheter aortic valve replacement (TAVR) has afforded an alternative to surgical aortic valve replacement (SAVR) for high-risk or non-operative candidates for aortic valve surgery.  However, the adoption of TAVR may not be limited to the patient population for who the procedure has studied and outcomes in routine clinical practice may not reflect those of prior randomized trials. In this retrospective study including data on all TAVR and SAVR procedures in Germany from 2007 to 2013, the authors examine the use of these procedures in clinical practice and associated patient outcomes.  A total of 32,581 TAVI and 55,992 SAVR (without concomitant revascularization) were performed during this period.  Use of TAVR increased from 144 procedures in 2007 to 9147 in 2013, while the number of SAVRs decreased from 8622 to 7048 over the same period.  Compared with patients receiving SAVR, patients receiving TAVR were older (81.0±6.1. years vs 70.2±10.0 years) and higher risk as assessed by logistic EuroScore (22.4% vs 6.3%).  Over the period of study, in-hospital mortality following TAVR decreased from 13.2% to 5.4%.  Concurrently, in-hospital mortality following SAVR declined from 3.8% to 2.2%.  Importantly, the risk-score for patients undergoing TAVR increased over time, suggesting improvements in mortality were not a result of increasing use of TAVR in a lower risk population.  Complications of permanent pacemaker implantation were higher following TAVR (17.7% vs. 4.0%, P<0.001) as were rates of stroke (2.5% vs. 1.8%, P<0.001), and acute kidney injury (5.5% vs. 3.0%, P<0.001) while bleeding events were less frequent following TAVR (8.2% vs. 14.0%,  P<0.001).

Conclusions

In a nationwide evaluation of TAVR and SAVR performed in Germany between 2007 and 2013, there was a large increase in the use of TAVR that did not appear related to expanded use in lower risk patients.  Furthermore, outcomes of both TAVR and SAVR improved during this period.  These findings are consistent with a learning curve in the use of TAVR and highlight the importance of continued evaluation of the use and outcomes of this procedure in routine practice to ensure optimal patient care.

Summarized by Hussain Contractor and Steven M. Bradley

Reinöhl J, Kaier K, Reinecke H, Schmoor C, Frankenstein L, Vach W, Cribier A, Beyersdorf F, Bode C and Zehender M. Effect of Availability of Transcatheter Aortic-Valve Replacement on Clinical Practice. N Engl J Med. 2015 Dec 17;373(25):2438-47.