Abstract 3044: Transcatheter Aortic Valve Implantation in 168 High-Risk Patients with Symptomatic Severe Aortic Stenosis - Single Centre Experience
Robert BooneLukas AltweggJean‐Bernard MassonAbullah Al AliSaad Al BugamiSanjeevan PasupatiLee MayRonald G. CarereRobert R. MossBrad MuntCheung AnsonJian YeChristopher ThompsonSamuel V. LichtensteinJohn G. Webb
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Objectives: We describe the outcome of 168 patients with severe symptomatic aortic stenosis treated with transcatheter aortic valve implantation (TAVI). This cohort includes the first in man transarterial and off-pump transapical patients. Methods: The balloon-expandable aortic prosthesis was implanted via the femoral artery or left ventricular apex in 113 and 58 patients respectively. Data are described as 1–57, 58 –114 femoral and 1–58 apical procedures, respectively. Clinical and echocardiographic follow-up occurred at 1, 6, 12, and 24 months. Unsuccessful cases were censored at 30 days. Results: Mean age was 82.5 years (range 50 –97) with 57% males. Procedural success was 94.2% [88%, 96%, & 98%] with no unsuccessful procedures in the last 46 cases. One patient had a successful transfemoral procedure after a prior failure, and 3 patients had successful transapical procedures following failed transfemoral attempts. Logistic EuroSCORE and STS predicted 30-day surgical mortality was 31% [28.4%, 29.1% & 36%], and 10.4% [8.9%, 9.6% & 12.6%] respectively. Observed 30-day mortality was 10.5% [10.5%, 3.5%, & 17.2%], and 0% in the last 39 trans-femoral cases. Intra-procedural mortality was 1.1% [1.8%, 0% & 1.7%]. Peri-procedural stroke occurred in 4% [3.5%, 7%, & 1.7%]. Median hospital stay was 5 days [4, 5, & 7]. Survival at 1, 6, 12 and 24 months was 88%, 80%, 74% [73.9%, 84%, & 65.6%] and 61%. AVA, MG, LVEF and MR significantly improved post TAVI (Table 1 ), and MR, EF, and NYHA class significantly improved during follow-up. MG did not increase during follow-up, but AVA decreased slightly at 1 year (mean difference: 0.2±0.54cm 2 , p=0.04). Mild paravalvular AR was common but severe AR was not observed post-implant or at follow-up. Conclusion: TAVI provides sustained clinical benefit for up to 2 years in patients with symptomatic severe AS and high operative risk. Procedural outcome continues to improve with experience and device development. Table 1: Echocardiographic follow-upKeywords:
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Objective With the advent of transcatheter aortic valve implantation (TAVI) has come an expectation that there will be a decline in surgical aortic valve replacement (SAVR). This has been fueled by trials comparing outcomes between TAVI and SAVR in lower-risk patients. The aim of this study was to examine outcomes following SAVR in patients over the age of 60. Materials and Methods This retrospective cohort study observed 1005 patients ≥60 who underwent isolated primary SAVR from January 2015 to December 2018. The cohort was stratified by surgical risk, defined as European System for Cardiac Operative Risk Evaluation (EuroSCORE) II < 4 versus ≥4. The cohort was also divided by age (60–69, 70–79, ≥80) for additional comparisons. Outcomes included in-hospital complications and patient survival. Results The median age and EuroSCORE II were 75 years and 1.6, respectively. The overall 30-day mortality was 1.7% and increased significantly with surgical risk (p = .007). The 30-day mortality of elective patients was 1.1%. Overall, 1- and 2-year survival rates were 94.3% and 91.7%, respectively, which significantly decreased with surgical risk (p < .001) and age (p = .002, p = .003). The rates of postoperative stroke and pacemaker implantations were 1.2% and 3.6%, respectively. Conclusions SAVR can be performed in patients ≥60 years old with excellent outcomes, which compare favorably with outcomes from TAVI trials, with their highly selected patient cohorts. SAVR remains a reliable, tried and tested, treatment option in these patients.
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Objectives: One of the most prominent scores for the evaluation of procedural risk in cardiac surgery is the EuroSCORE. The aim of our study was to analyze the predictive value of the EuroSCORE in „high risk“ patients undergoing isolated aortic valve replacement (AVR).
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Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.
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The aim of the study was to assess the predictive ability of risk calculators of the EuroSCORE II and the Society of Thoracic Surgeons (STS) score in patients undergoing aortic valve replacement (AVR) due to severe aortic valve stenosis (AS) during a 30-day and 1-year follow-up.A prospective study was conducted on a group of consecutive patients with hemodynamically significant aortic valve stenosis that underwent elective valve replacement surgery. The risk of surgery using EuroSCORE II and STS was calculated for each patient. The primary and secondary endpoints were 30-day and 1-year mortality.The study group included 428 consecutive patients who underwent replacement of the aortic valve. Thirteen patients died during the 30-day follow-up and 25 patients died during 1-year follow-up. Actual mortality in 30-day observation was 3.0% compared to the predicted 2.9% using EuroSCORE II and 2.1% for STS. The discriminations of ES II and STS score were above 0.8 for mortality prediction during the 30-day and 1-year observation period.The EuroSCORE II and STS score showed satisfactory discrimination and calibration for predicting 30-day and 1-year mortality in patients undergoing AVR.
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Logistic EuroSCORE overestimates the risk profile of octogenarians undergoing aortic valve replacement by traditional surgery. EuroSCORE II, that was created in an attempt to improve this previous version, has been evaluated in the general population. However, to our knowledge, there are no studies evaluating the predictive performance of EuroSCORE II in the elderly population undergoing surgery for aortic valve replacement despite the fact that the majority of patients receiving transcatheter techniques are octogenarians and this new version is being used for the selection of high-risk surgical patients.
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Objectives:Evaluation of the risk for post-operative delirium (POD) after surgical or transfemoral aortic valve replacement (AVR) as an additional decision parameter for the choice of treatment in patients with an EuroScore (ES) between 10% and 20%.Background:POD is well known as a not infrequent side effect of cardiac surgery necessitating extracorporeal circulation. In Germany a tendency to treat patients with ES <20% with transfemoral AVR (TF) instead of surgical AVR (SAVR) was observed in 2013. The risk of POD may influence the decision of physician and patient as to which procedure would be appropriate in the individual case. Therefore we performed an analysis of the incidence of POD in patients with comparable risk treated either with surgical or transfemoral aortic valve replacement.Methods:Patients with elective or urgent need for AVR and EuroScore between 10% and 20% were extracted from the database of all isolated AVR procedures in Germany of 2013. As a result 3407 cases, 771 SAVR patients and 2636 TF patients with EuroScore 10–20%, were extracted from the complete data-base of the German quality insurance registry for heart surgery. Two homogeneous groups with regard to the risk predicted by ES were built by case–control matches and compared for available variables. In a second step two groups with identical risk/co-morbidity profile for 10 variables were identified and analyzed with respect to POD and in-hospital mortality.Results:A total of 763 pairs with EuroScore of 13.5% each could be determined. Mean age was 75.6 years (SAVR, 51.6% male) and 78.8 years (TF, 56.5% male). Incidence of POD with need for therapy (POD-T) was 12.8% after SAVR and 3.8% after TF, resulting in numbers needed to harm of 8 and 26 respectively. In-hospital death rate of patients with POD-T was 5.1% after SAVR and 3.3% after TF, and nearly identical compared with patients without POD-T. POD-T had a negative influence on the regular discharge procedure. Further matching resulted in two groups of 470 patients each with identical co-morbidities and an age difference of 1 year but POD-T rates of 14.5% (SAVR) and 4.9% (TF); in-hospital mortality was 6.2% (SAVR) and 2.3% (TF).Limitations:The dataset contains valid data only for the period of hospital stay until discharge. Therefore conclusions about the duration and reversibility of POD, which are important parameters of quality of life and resource consumption as well as midterm consequences, cannot be estimated. The documentation of the German Federal Council asks only for POD and POD-T, a predefined definition of POD is not given; this may have some influence on the data. We therefore confined the analysis to only POD-T. In addition only a limited number of co-morbidities are documented.Conclusion:In patients with intermediate risk according to EuroScore (10–20%) the risk of post-operative delirium and in-hospital mortality is significantly higher after surgical aortic valve replacement than after transfemoral procedure. This may be considered for patient guidance and the decision as to which procedure is able to achieve the best result including minimizing side effects.
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