TAVR Feasible, Comparable to Surgery in Rheumatic Heart Disease

Patrice Wendling

April 06, 2021

Patients with rheumatic heart disease (RHD) appear to have comparable outcomes, whether undergoing transcatheter or surgical aortic valve replacement (TAVR/SAVR), and when compared with TAVR in patients with nonrheumatic aortic stenosis, a new Medicare study finds.

An analysis of data from 1159 Medicare beneficiaries with rheumatic aortic stenosis revealed that over a median follow-up of 19 months, there was no difference in all-cause mortality with TAVR vs SAVR (11.2 vs 7.0 per 100 person-years; adjusted hazard ratio [aHR], 1.53; P = .2).

Mortality was also similar after a median follow-up of 17 months between TAVR in patients with rheumatic aortic stenosis and 88,554 additional beneficiaries with nonrheumatic aortic stenosis (15.2 vs 17.7 deaths per 100 person-years; aHR, 0.87; = .2).

"We need collaboration between industry and society leaders in developed countries to initiate a randomized control trial to address the feasibility of TAVR in rheumatic heart disease in younger populations who aren't surgical candidates or if there's a lack of surgical capabilities in countries, but this is an encouraging first sign," lead author Amgad Mentias, MD, MSc, Cleveland Clinic Foundation, told theheart.org | Medscape Cardiology.

Although the prevalence of rheumatic heart disease (RHD) has fallen to less than 5% or so in the United States and Europe, it remains a significant problem in developing and low-income countries, with more than 1 million deaths per year, he noted. RHD patients typically present at younger ages, often with concomitant aortic regurgitation and mitral valve disease, but have less calcification than degenerative calcific aortic stenosis.

Commenting on the results, published April 5 in the Journal of the American College of Cardiology, David F. Williams, PhD, said in an email that "it is only now becoming possible to entertain the use of TAVR in such patients, and this paper demonstrates the feasibility of doing so."

"Although the study is based on geriatric patients of an industrialized country, it opens the door to the massive unmet clinical needs in poorer regions as well as emerging economies," said Williams, a professor at the Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina, and coauthor of an accompanying editorial.

The study included Medicare beneficiaries treated from October 2015 to December 2017 for rheumatic aortic stenosis (TAVR, n = 605; SAVR, n = 55) or nonrheumatic aortic stenosis (n = 88,554).

Among those with rheumatic disease, SAVR patients were younger than TAVR patients (73.4 vs 79.4 years), had a lower prevalence of most comorbidities, and were less frail (median frailty score, 5.3 vs 11.3).

SAVR was associated with significantly higher weighted risk for in-hospital acute kidney injury (22.3% vs 11.9%), blood transfusion (19.8% vs 7.6%), cardiogenic shock (5.7% vs 1.5%), new-onset atrial fibrillation (21.1% vs 2.2%), and had longer hospital stays (median, 8 vs 3 days), whereas new permanent pacemaker implantations trended higher with TAVR (12.5% vs 7.2%).

The TAVR and SAVR groups had comparable rates of adjusted in-hospital mortality (2.4% vs 3.5%), 30-day mortality (3.6% vs 3.2%), 30-day stroke (2.4% vs 2.8%), and 1-year mortality (13.1% vs 8.9%).

Among the two TAVR cohorts, patients with rheumatic disease were younger than those with nonrheumatic aortic stenosis (79.4 vs 81.2 years); had a higher prevalence of heart failure, ischemic stroke, atrial fibrillation, and lung disease; and were more frail (median score, 11.3 vs 6.9).

Still, there was no difference in weighted risk of in-hospital mortality (2.2% vs 2.6%), 30-day mortality (3.6% vs 3.7%), 30-day stroke (2.0% vs 3.3%), or 1-year mortality (16.0% vs 17.1%) between TAVR patients with and without rheumatic stenosis.

"We didn't have specific information on echo[cardiography], so we don't know how that affected our results, but one of the encouraging points is that after a median follow-up of almost 2 years, none of the patients who had TAVR in the rheumatic valve and who survived required redo aortic valve replacement," Mentias said. "It's still short-term but it shows that for the short- to mid-term, the valve is durable."

Data were not available on paravalvular regurgitation, an Achilles heel for TAVR, but Mentias said rates of this complication have come down significantly in the past 2 years with modifications to newer-generation TAVR valves.

Williams and his editorial colleagues say one main limitation of the study also highlights the major shortcoming of contemporary TAVRs when treating patients with RHD: "namely, their inadequate suitability for [aortic regurgitation] AR, the predominant rheumatic lesion of the aortic valve" in low- to middle-income countries.

They point out that patients needing an aortic valve where RHD is rampant are at least 30 years younger than the 79-year-old TAVR recipients in the study.

Commenting to Medscape Medical News, Williams said there are several unanswered questions about the full impact TAVR could have in the treatment of young RHD patients in underprivileged regions. "These mainly concern the durability of the valves in individuals who could expect greater longevity than the typical heart valve patient in the USA, and the adaptation of transcatheter techniques to provide cost-effective treatment in regions that lack the usual sophisticated clinical infrastructure."

Mentias received support from National Institute of Health NRSA institutional grant to the Abboud Cardiovascular Research Center . Coauthor disclosures are listed in the paper. Zilla, Williams, and Bezuidenhout are directors of Strait Access Technologies.

J Am Coll Cardiol. 2021;77:1703-1713, 1714-1716. Abstract, Editorial

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