TAVR is safe for patients with large aortic annuli—heart failure remains a concern
Transcatheter aortic valve replacement (TAVR) is a safe treatment option for patients with large or extra-large aortic annuli, according to new findings published in JTCVS Open.[1] In fact, it compares favorably to surgical aortic valve replacement (SAVR), which is already known to accommodate patients with larger aortic annuli.
“Patients with extra-large annuli may represent the anatomic limits of current transcatheter platforms,” wrote first author Xander Jacquemyn, MD, a cardiothoracic surgery resident with the University of Pittsburgh Medical Center, and colleagues. “Nonetheless, several studies have reported use of these platforms in annuli that are outside these recommended size ranges. In contrast, surgical prostheses can accommodate a wide range of annular sizes, offering greater flexibility in the treatment of patients with large or extra-large anatomy. Although TAVR has demonstrated favorable outcomes across a range of patient populations and annular anatomies, the clinical profile of patients with large or extra-large trileaflet aortic annuli remains incompletely characterized, particularly in the context of both transcatheter and surgical strategies.”
Jacquemyn explored data from 414 patients who presented for aortic valve replacement at a single facility with a large or extra-large aortic annuli. While 85% of patients underwent TAVR, the others underwent SAVR. The median age was 78.8 years old, though SAVR patients tended to be much older, and nearly 5% were women. TAVR patients presented with a much higher burden of comorbidities than SAVR.
For the sake of this study, a large aortic annuli was defined as one with an annular area ≥575 mm2 or perimeter ≥85 mm. An extra-large aortic annuli was defined as one with an annular area ≥683 mm2 or perimeter ≥94.2 mm.
Overall, 30-day mortality occurred in just 0.9% of TAVR patients and no SAVR patients. Long-term mortality was significantly higher for TAVR, the researchers wrote, but this also matches with the much higher risk profile of patients undergoing TAVR.
Heart failure (HF) rehospitalizations were more common for patients treated with TAVR than those treated with SAVR. Congestive HF, the authors added, was the one variable independently linked to an increased risk of HF rehospitalization.
The study’s authors emphasized that TAVR patients were sicker and faced more risks, which appears to be the primary explanation for the higher mortality rates. At the same time, the difference in HF rehospitalization rates is something clinicians will want to keep in mind going forward.
Jacquemyn and colleagues noted that lifetime management is something care teams should continue to take seriously when making treatment decisions for patients with larger aortic annuli. For example, there is always a risk of structural valve deterioration causing issues over time that require additional reinterventions. And in patients with larger aortic annuli, valve-in-valve options may be limited due to concerns about “residual gradients and patient-prosthesis mismatch within the existing surgical frame.” On the other hand, “large-frame transcatheter prostheses may offer more favorable valve-in-valve landing zones.”
These different points make it clear just how important it is to make these care decisions on a case-by-case basis.
“For younger patients with large annuli who are suitable for both approaches, a heart team discussion that explicitly incorporates lifetime management strategy, including projected valve durability and future reintervention options, is strongly recommended,” the authors wrote. “Furthermore, although our data demonstrate that both approaches yield outcomes consistent with the underlying patient risk profile, with SAVR achieving population-level survival in appropriately selected patients and TAVR reflecting the higher comorbidity burden, the persistence of significantly higher HF hospitalization after TAVR even after multivariable adjustment argues for careful patient selection.”
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.