Transcatheter vs Surgical Aortic Valve Replacement Show Different Benefits Over Time

A recent study found that when it comes to treating calcific aortic stenosis in patients with end-stage renal disease (ESRD) and heart failure with reduced ejection fraction (HFrEF), transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) offer distinct advantages at different stages of care.

According to the research, which was published in The American Journal of Cardiology, TAVR is linked to better short-term outcomes while SAVR led to better long-term outcomes.

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TAVR has emerged as the preferred standard of care for patients dealing with calcific aortic stenosis. However, a significant gap in knowledge existed, particularly concerning patients with ESRD on hemodialysis, as they were often excluded from pivotal trials that established TAVR's safety and efficacy. Data from a national registry also demonstrated that this vulnerable population experienced notably higher in-hospital and 1-year mortality rates compared with patients not on hemodialysis. Additionally, limited information was available regarding outcomes for patients with ESRD and HFrEF who underwent surgical interventions compared to transcatheter procedures.

To bridge this critical knowledge gap, researchers used the United States Renal Data System to identify all patients with ESRD, aortic stenosis, and HFrEF who had undergone TAVR, SAVR, or initiated dialysis after 2012, and compared survival. A comprehensive analysis was conducted using Kaplan-Meier survival curves.

The study included 7660 patients, of whom 66.1% were male, with a median (IQR) age at dialysis initiation of 73 (65-80) years. Of this group, 14.5% of patients had undergone TAVR and 9.1% had undergone SAVR.

The results showed that patients who underwent TAVR experienced improved survival rates compared with those under medical management. Additionally, in-hospital outcomes were in favor of TAVR, with lower in-hospital mortality rates (4.5% vs 9.1%; P = .002) and fewer complications observed compared with SAVR. Looking at specific complications, patients who underwent SAVR had higher rates of stroke (2.6% vs <2.0%; P = .037), cardiogenic shock (14.4% vs 6.5%; P < .001), median intensive care days (10 vs 3; P < .001), and length of hospital stay (14 vs 6 days; P < .001) compared with patients who underwent TAVR.

“This is consistent with seminal trials in TAVR and is likely a result of a minimally invasive approach and avoidance of cardiopulmonary bypass,” the study authors said. On the other hand, TAVR was linked to a higher rate of pacemaker implantation (4.1% vs 2.1%; P = .052).

While the short-term, in-hospital outcomes generally favored TAVR, survival curves eventually crossed at approximately 9 months, with SAVR offering superior long-term mortality outcomes. One-year survival was slightly higher for SAVR at 64.2%, compared with 63% for TAVR (P = .683). This difference became more clear as time went on, as 2-year survival was 35.8% for TAVR and 45.9% for SAVR (P < .001).

According to the authors, the reason for this change over time is unclear, though it has been found in other similar studies comparing TAVR to SAVR with other major comorbidities.

“In part, the decision to proceed with TAVR in our cohort may be based on unmeasured risk factors but all co-morbidities were similar between groups after propensity matching,” they said. “The improved survival with SAVR could be explained by reduced durability of TAVR valves, however, recent studies have shown lower rates of structural valve degeneration when comparing bioprosthetic SAVR to TAVR.”

They also noted that this may be due to the increased risk of paravalvular leak in TAVR, though the incidence of significant paravalvular leak is very low based on current available data.

Additionally, 19 patients who underwent SAVR and fewer than 11 patients who underwent TAVR required reintervention (P = 0.09).

“Randomized controlled trials are needed to definitively determine the best method of AVR in patients with ESRD,” the authors added. “These trials should include patients with HFrEF to evaluate mortality and quality of life benefits in this patient population.”

Reference

Warner ED, Riley J, Liotta M, et al. Aortic Valve Replacement in patients with ESRD and heart failure with reduced ejection fraction. Am J Cardiol. 2023;205:111-119. doi:10.1016/j.amjcard.2023.07.161