TAVR vs. SAVR in patients with pure aortic regurgitation: Key insights from a new Cleveland Clinic study
Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are associated with similar short-term outcomes among patients with pure native aortic regurgitation (AR), according to new data published in The Annals of Thoracic Surgery.[1]
The study’s authors noted that patients with pure native AR are often excluded from clinical trials comparing TAVR and SAVR. In addition, they noted, the few studies that have examined this issue have focused on “relatively small” patient populations.
Hoping to provide a more comprehensive look at this topic, first author Amgad Mentias, MD, a cardiologist with the Heart, Vascular and Thoracic Institute at Cleveland Clinic, and colleagues tracked data from more than 11,000 Medicare patients. All patients presented with pure AR and underwent TAVR or SAVR from 2016 to 2019. Patients presenting with a history of aortic stenosis were excluded from this analysis.
While 89.5% of patients underwent SAVR, the remaining 10.5% underwent TAVR. SAVR patients tended be younger and less frail than TAVR patients. SAVR patients also presented with fewer comorbidities.
Overall, TAVR and SAVR patients were linked to comparable in-hospital mortality, 30-day mortality and 30-day stroke rates. After a median follow-up period of 31 months, however, TAVR patients were associated with a higher mortality rate and higher risk of redo aortic valve replacement.
“The poorer intermediate-term outcomes with TAVR in our study could potentially be due to residual unmeasured differences and surgical risk between the two groups, but could also be related to the anatomical differences between pure severe AR and aortic stenosis,” the authors wrote. “The increased prevalence of bicuspid leaflets and annular/aortic root dilation in AR patients, with relatively less leaflet and annular calcification, pose a challenge with transcatheter heart valve anchoring and adequate positioning and increase the risk of paravalvular leak and device embolization. Abnormal hemodynamics across prosthetic valves and paravalvular leakage, whether mild or moderate/severe, are known predictors of poor outcomes, including death. The recommendation to oversize the THV during implantation is also associated with increased risk of aortic rupture and conversion to open heart surgery, a complication that was observed in 1% of TAVR patients in our study.”
TAVR was also associated with a much lower risk of in-hospital acute kidney injury and new-onset atrial fibrillation. In addition, TAVR patients were less likely to require a blood transfusion and, as one might expect, they had shorter lengths of stay.
“Randomized trials of SAVR compared with new transcatheter heart valves dedicated for pure AR with extended follow-up are awaited,” the authors concluded.
Though a majority of the study’s authors were from the Cleveland Clinic, co-authors from The Warren Alpert Medical School of Brown University, Baylor College of Medicine and University of Iowa Carver College of Medicine also contributed.
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.