Technically inoperable patients fare best after TAVR

Transcatheter aortic valve replacement (TAVR) patients who are inoperable because of technical reasons have better outcomes than TAVR patients who are clinically inoperable, a finding that could help identify patients likely to reap the greatest benefit from the procedure.

The results appeared in the March 11 issue of the Journal of the American College of Cardiology.

Raj R. Makkar, MD, of Cedars-Sinai Heart Institute in Los Angeles, and colleagues conducted a retrospective study using data from patients in PARTNER (Placement of Aortic Transcatheter Valve) cohort B and inoperable patients in the continued access registry. PARTNER cohort B showed that inoperable patients with severe aortic stenosis who underwent TAVR had significantly better survival benefits compared with patients given standard therapy (ST).

TAVR patients may be considered inoperable for technical reasons such as porcelain aorta or chest wall deformity or for clinical reasons such as comorbidities or frailty. Makkar et al wanted to examine if outcomes differed based on these subclassifications. The analysis included 369 inoperable TAVR patients, with 23 percent considered technically inoperable (TI) and 77 percent clinically inoperable (CLI). The 34 patients deemed inoperable for a combination of technical and clinical reasons were defined as CLI.

The most common reason for TI was porcelain aorta, followed by hostile chest, mostly because of previous radiation exposure. Comorbidities, frailty and lung disease led the reasons for CLI.

TI patients tended to be younger and healthier than CLI patients. They had lower all-cause mortality at one year and two years compared with CLI patients (14.1 percent vs. 32 percent and 23.1 percent vs. 43.8 percent, respectively).

The two-year mortality rate for patients deemed both technically and clinically inoperable was similar to the CLI group. Those patients also had a higher rate of emergent conversion to open heart surgery during TAVR, late stroke and transient ischemic attack compared with patients who were solely clinically inoperable.   

A higher Society of Thoracic Surgeons score and clinical inoperability were significant independent predictors of all-cause mortality.

At one year, 24.6 percent of the CLI group had persistent severe symptomatic heart failure compared with 10.6 percent in the TI group. The TI group also had greater improvement in quality of life measures, with the exception of the mental score.

“[A]lthough the TI group had the best clinical outcome data, cases from the CLI group whose inoperability was compounded with technical reasons did worse than TI patients but also worse compared with CLI patients who had no additional technical reasons for inoperability, most notably with more cerebrovascular events,” they wrote.

Their results may be useful in patient selection for TAVR. TI patients were “excellent candidates for TAVR” because they had a lower risk profile, better survival and greater improvements in quality of life. “In contrast, patients inoperable for clinical reasons are a heterogeneous group whose outcomes after TAVR seem reasonable compared with ST but inferior to those of TI patients.”