Circ: TAVI trumps SAVR in stenotic patients with decreased LVEF
"Patients with severe aortic stenosis and reduced LVEF have a poor prognosis with conservative therapy but a high operative mortality when treated surgically," the authors wrote.
To better evaluate the emerging TAVI approach, Marie-Annick Clavel, DVM, MS, of the Laval University in Quebec, Canada, and colleagues evaluated the outcomes of 200 patients undergoing SAVR and 83 patients undergoing TAVI. All patients had severe aortic stenosis and a reduced LV function.
Patients undergoing TAVI were older and had more chronic conditions compared with SAVR patients.
At baseline, patients in both groups exhibited LVEF numbers that were in the range of 34 percent. After repair, TAVI patients had a better recovery of LVEF compared to SAVR patients, 14±15 percent versus 7±11 percent, respectively.
Of the trial cohort, 180 SAVR patients had complete revascularization or did not need revascularization compared with 36 of the TAVI patients.
At one-year, 58 percent of those treated with TAVI had a normalization of LVEF that was less than 50 percent compared to 20 percent of patients in the SAVR arm.
The researchers also adjusted for gender, LVEF, absence of atrial fibrillation, TAVI and a larger increase in aortic valve area after the procedure. These patient subsets all saw a better LVEF recovery, according to the authors.
Additionally, 30 days post-procedure, 24 patients in the SAVR group and 16 in the TAVI group died. Patients who were older, had a history of MI and open heart surgery, a presence of mitral regurgitation and STS score (OR per 1-point increase) were all strong individual predictors of 30-day mortality.
"The operative risk associated with SAVR may vary extensively among patients with severe aortic stenosis and depressed LV systolic function. It thus appears judicious to individualize the therapeutic strategy according to the patient’s baseline risk profile and to refer only patients who have a high or prohibitive surgical risk to TAVI," the researchers wrote.
However, despite limitations, the authors concluded: "TAVI may provide an interesting alternative to SAVR in patients with depressed LV systolic function considered at high surgical risk."