TAVR vs SAVR: Aortic-Stenosis Patients Fare Better Early With TAVR But Even Out Long Term

Larry Hand

November 07, 2016

WASHINGTON, DC — Patients who are treated for aortic stenosis with transfemorally accessed transcatheter aortic-valve replacement (TAVR) experience an increase in quality of life (QoL) early on compared with patients treated with surgical aortic-valve replacement (SAVR), according to research presented at    TCT 2016[1].

"Taken together with previous data, these findings demonstrate that for intermediate-risk patients suitable for a transfemoral approach, TAVR provides     early and late benefits over surgical AVR from the patient's perspective," Dr David J Cohen (St Luke's Mid-America Heart Institute, Kansas City, MO) said.

However, he added, "The lack of benefit among patients ineligible for the transfemoral approach suggests that a transthoracic approach may not be     preferable to SAVR in such patients—at least in the short to intermediate term."

In the PARTNER 2A trial between 2011 and 2013, Cohen and colleagues randomized 2032     aortic-stenosis patients to either TAVR (n=1011) with the Sapien XT valve (Edwards Lifesciences) or SAVR (n=1021). They measured patient quality     of life at baseline and at 1, 12, and 24 months using the Kansas City Cardiomyopathy Questionnaire (KCCQ).

They found that KCCQ overall scores, the primary end point, improved by 19.2 points in patients treated with transfemoral-access TAVR compared with 18.3     points with patients treated with SAVR. A score of 10 points is rated as medium improvement and 20 points is rated at large improvement.

"The patients started off quite impaired with a mean KCCQ score of 53 [on a scale of 0–100, with higher scores reflecting better quality]," Cohen said.     "Over the next month both groups improved, but the improvement was much greater among the patients treated with TAVR, with a difference between the groups     of 11 points [P<0.001]. Over the next 11 months, the surgical group did catch up. There was no significant difference at 12 months or at 24     months."

"Similar to what we've seen in previous studies, there was a significant interaction between the treatment benefit for TAVR and the access site both for     the primary end point and for multiple secondary end points," he explained. "In contrast, in the transthoracic subgroup, including transapical and     transaortic access, there was no benefit of transcatheter aortic-valve replacement for the KCCQ overall score at any time."

Dr Jeffrey J Popma (Beth Israel Deaconess Medical Center, Boston, MA) commented on the findings. "We have seen repeatedly in the transfemoral-vs-surgery     trials that a 6-month period is not good for surgery, it's great for transfemoral. I've always wondered how much of that lack of improvement in quality of     life is due to a complicated surgery vs an uncomplicated surgery."

Dr Gregg Stone (Columbia University Medical Center, New York) commented that the results mirror results found in studies comparing TAVR with PCI.

"Strikingly similar," echoed Dr Eric D Peterson (Duke University School of Medicine, Durham, NC), who had a suggestion for future research.

"Between 1 and 12 months is a large gap. I know it's a burden on patients, but I think in future work what you might want to think about, 3 months, 2     months, continuing out to the 12 months," he said.

Researchers might also want to "tease out the degree to which patient characteristics or the idea of the surgery itself" leads to differences in QoL, he     added.

Cohen summed up: "The most important finding is that there was significant interaction between the treatment effect and the access site. There doesn't seem     to be a benefit of doing TAVR—that I can measure—if you can't do it transfemorally. The message here is 'stay out of the chest.' "

        Edwards Life Sciences funded the PARTNER II trial. Cohen reported receiving research support from Edwards Lifesciences, Medtronic, Abbott Vascular, and         Boston Scientific and consulting income from Medtronic and Abbott Vascular.    

Follow Larry Hand on Twitter: @LarryHand16. For more from theheart.org, follow us on Twitter and        Facebook.    

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