SAVR and TAVR: The Role of the Heart Team Towards a Tailored
Approach.
Benoit de Varennes MDCM, MSC, FRCS
McGill University Health Centre
Division of Cardiac Surgery
1001 Boul. Décarie
Montréal, QC, Canada H4A 2M3
benoit.devarennes@muhc.mcgill.ca
In this issue of the Journal (1), a group from the Université de
Montréal, Canada, describes a retrospective analysis of 812 consecutive
intermediate-risk patients who were treated for isolated aortic stenosis
between 2012 and 2019. All patients who underwent trans-catheter aortic
valve replacement (TAVR) were rigorously reviewed by a Heart Team and
bioprosthetic surgical aortic valve replacement (SAVR) patients done
during the same period were included. The authors do not mention on
which basis surgical patients received the treatment.
Applying propensity matching, a total of 139 patients were retained in
each group. The trans-femoral approach for TAVR was used in 86% of
patients with the Edwards Sapien platform used in the majority of
patients. 99% of surgical patients were done through a full median
sternotomy using almost exclusively the Edwards Magna or Perimount
prostheses.
As expected, the types of complications greatly differed between the 2
groups: TAVR was associated with higher rates of transient ischemic
attacks, need for permanent pacemaker and para-valvular leak. SAVR was
associated with increased rates of acute kidney injury, atrial
fibrillation, delirium, infections, bleeding complications and increased
length of stay. The STS predicted 30-day mortality was similar between
the 2 groups (4,5% for SAVR, 4,8% for TAVR). The observed mortality
was not significantly different for the 2 cohorts (SAVR=4,5% TAVR=0,7%p =0,053) in the matched analysis. Such results have already been
described in many trials, the most well-known being Partner 2A (2).
What makes this paper interesting is the angle the authors have given to
their data. The evolution of the trend from SAVR to TAVR between 2012
and 2019 in this academic center is not mentioned in the paper. The
matched analysis indicates that there were similar numbers of patients
in each cohort for each 2-year block, but we can safely assume that over
that period, the population of SAVR vs TAVR has significantly changed
like in all other busy centers. It is likely that ALL patients (or the
majority) requiring treatment for aortic stenosis are now evaluated by a
Heart Team as opposed to the beginning of their series. This usually
causes a paradigm shift in which aortic stenosis patients who are NOT
candidates for TAVR (root anatomy, sub-annular calcifications, etc.) end
up in the surgical arm. These patients usually carry quite an elevated
risk of mortality and complications which are not taken into account
with the current risk-prediction models (STS score, EURO score) we use
nowadays and may explain the trend towards a higher mortality. As more
and more of these patients will receive SAVR, a significant advantage
(as opposed to the current non-significant difference) will be seen as
an index of superiority favoring TAVR. This is where the Heart Team
approach is crucial as it is the only entity that can determine what the
best approach will be for individual patients. With this tailored
approach, cardiologists and surgeons will have to play a major role in
educating patients and referring physicians. The days of only quoting
literature results are over unless newer scoring systems are developed
and taking into consideration the anatomical limitations for each
approach.
The authors discuss the role of blood transfusions during SAVR leading
to higher rates of any morbidity/mortality. Minimal-access SAVR and
rapid-deployment SAVR being associated with lesser bleeding, shorter
length of stay and more rapid extubation (3,4) might mitigate the
results of this study as only 1% of the SAVR patients were done through
a minimal-access approach. Using those newer techniques might
potentially narrow the gap between TAVR and SAVR.
While the mortality trends for SAVR have been quite stable over the last
decade, the authors have demonstrated a clear reduction in the observed
mortality of patients being treated for aortic stenosis (TAVR and SAVR
combined) in this experienced academic center between 2019 and 2019.
This can only be explained by the role of the Heart Team in tailoring
the approach to such patients.
The authors should be commended for their work.
Benoit de Varennes
MDCM, MSc, FRCS
McGill University Health Centre