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5yr

Aortic stenosis (AS) is the most common heart valve disease, characterized by the narrowing of the aortic valve due to progressive calcification. Treatment paradigms have shifted to expand the use of less-invasive transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR). Since TAVR approval in 2013, the FDA has granted multiple label expansions to include a “valve-in-valve” procedure for failed surgical bioprosthetic valves (2015), use in patients with severe AS at intermediate risk (2016), and use in severe AS patients with low surgical risk (2019). This represents a significant advancement as 75% of severe AS patients are categorized as low-to-intermediate surgical risk.

In the PARTNER 3 study, which compared TAVR to SAVR in low-risk patients, the findings showed:
the primary composite endpoint of death, stroke, or rehospitalization was significantly lower in the TAVR group (8.5% vs. 15.1%; p<0.001)
TAVR had a shorter index hospitalization (p<0.001)
at 30 days there was a lower stroke risk and lower incidence of new atrial fibrillation in the TAVR group
Though there was a higher incidence of new Left Bundle Branch Block in the TAVR group, there was not a significant difference in the need for a permanent pacemaker in the two groups.

1. What are the clinical triggers that would prompt you to consider TAVR intervention in severe AS patients with low-to-intermediate surgical risk?
2. In which types of patients do you believe TAVR is preferable to SAVR?
3. What are the potential advantages and disadvantages of conducting TAVR versus SAVR in patients with severe aortic stenosis?

  • 5yr
    Symptomatic aortic stenosis is an indication for TAVR: dyspnea, syncope, acute CHF or angina.
    I prefer TAVR for moderate to high risk patients, elderly patients and patient's on chemotherapy. Recovery is easier after TAVR and its especially important for oncology patients on active chemotherapy. Patient's who have stenosis of the bioprosthetic AV or previous CABG or radiation to the chest are better candidates for TAVR .
    Advantages : easier recovery, less complications, short hospital stay, lower infection risk
    Disadvantages: unclear longevity of the valve, risk for PPM need post-procedure, aortic regurgitation
  • 5yr
    The triggers are are symptoms such as exertional dyspnea or angina or syncope. In patients with severe aortic stenosis I do not wait for symptoms since there is an incidence of sudden death in those patients.
    TAVR is the primary treatment of severe aortic stenosis unless there is ascending aortic disease, severe triple vessel disease not amenable to PCI, there is also severe mitral disease. Small population with hypertrophic hyperkinetic LV that are recommended SAVR.
    Recovery is much faster, patients are discharged in 24 to 48 hours on average. Small risk of pacemaker and not knowing long term results are the downside
  • 5yr
    1. Generally it will be based on their symptoms the classic being Angina, HF or syncope, but decline in exertional capacity or functional abilities is another one. I typically follow them by doing low grade treadmill stress test over time to see how their functional capacity changes over time.

    2. While I strongly prefer TAVR for middle aged (40s and above) for younger pt i would still refer them to savr as long term valve durability of tavr is not really known. If there was a case to get valve in valve tavr down the road then i would be more comfortable in referring them for tavr procedure.

    3. TAVR has large advantages of being quicker procedure, less down time, less infection risk, less recovery time. I have seen more AI and slightly higher problems with heart block requiring PPM therapies with tavr. SAVR i have seen more infection complications, prolonged ICU stays, higher costs, and higher stroke rates.
  • 5yr
    I usually wait until the patient starts exhibiting symptoms of severe AS such as CHF, decreased exercise/activity tolerance, angina, or syncope. If I am unsure whether the patient is symptomatic, I sometimes have the patient perform a symptom limited exercise treadmill stress test. If the patient need concomitant CABG, additional valve surgery, or ascending aortic repair, then I recommend SAVR. Also, if the patient is under 50 years old, then I discuss SAVR versus TAVR and duration of valve longevity and possibility of mechanical AVR. TAVR is obviously more beneficial in patients who are elderly, have comorbidities, and have isolated AS. Advantages of TAVR over SAVR include much less invasive procedure, no need for putting patient on pump, length of stay, patient recovery, and overall cost. Disadvantage of TAVR is valve longevity and long-term outcomes of TAVR.
  • 5yr
    Since TAVR received initial FDA approval nearly a decade ago, indications for this procedure have inexorably expanded as indicated above, as valve and catheter technology has improved; as interventional cardiologists have gained experience, skills, and judgment; as Multispecialty Valve Teams have evolved (including CV surgeons, interventional cardiologists, imaging cardiologists, and others); and importantly, longitudinal outcomes data approaching a decade in length have become available. As such, the indications for TAVR vs, SAVR have a certain fluidity which we must recognize and accept. Certain hard-and-fast realities favoring SAVR remain, including the need for concomitant surgical procedure such as CABG or aortic surgery. But by 2021, it has been demonstrated that TAVR is superior in the oldest (or older) candidates, those for whom full-on surgery is a high risk, and those of limited natural lifespan. Even concern re. tissue TAVR longevity will likely yield to improved valve technology and valve-in-valve 2nd TAVR in the future. Educated patient preference of course figures into the equation.

    My point: current practices and guidelines are not hard and fast, so we practitioners must keep abreast of new trials, technological advancements, and clinical data to best inform our patients and our recommendations re. TAVR vs. SAVR.
  • 5yr
    Unless the pt requires CABG at the same time, or has bicuspid AV or significant AI, most pts will qualify for TAVR. Younger pts in general have bicuspid valves, so the younger pts in general will get SAVR. Only downside is unknown durability and probable need for future repeat TAVR
  • 5yr
    Durability and outcomes by implanter/ institution matter not discounting PVL and need for pacer.
    For me all patients qualify regardless of risk category and symptoms.
    Clearly all patients would prefer a less invasive procedure.
  • 5yr
    Indications to pursue aortic valve replacement in include symptom-dyspnea Cp syncope in the setting mean gradient > 40 mm Hg or evidence LV dysfunction related AS related afterload. The decision to consider SAVR vs TAVR depend on age comorbidities and risk. Younger patient and those with no comorbidities to contraindicate AVR should have SAVR. Although recent studies now support TAVR for lower and intermediate risk pts the risk of CVA in the literature and unknowns regarding valve longevity would not support TAVR for low risk patients for now.
  • 5yr
    Would consider TAVR in all symptomatic AS patients with low or moderate surgical risk except for those young patients who state they would prefer a mechanical valve for "durability," and those requiring concomitant CABG surgery or aortic root surgery.
    Certainly TAVR is preferable to SAVR in patients over the age of 65 especially those with a permanent pacemaker preoperatively (would avoid potential complication of need for permanent pacemaker), and certainly in the case of patients with prior median sternotomy incisions. SAVR is preferable in patients with bicuspid aortic valves, young patients for valve durability and patients with concomitant coronary atherosclerosis requiring CABG.
    Advantages of TAVR are the shorter hospital stay, shorter recovery time, lack of requirement for anticoagulation,. Disadvantages of TAVR are the not infrequent requirement for permanent pacemaker, the lack of durability of the valve, and the lack of approval for TAVR to treat aortic insufficiency.
  • 5yr
    1) symptoms including angina, CHF, syncope. Also I follow LV function and exercise tolerance. If patient says they are asymptomatic I often assess carefully with stress testing. More often than not they are assymptomatic as they have decreased their activity
    2) Tavr preferable in the higher risk, particularly in the older patienst , SAVR when they have other surgical conditions ( CAD, TAA, Mitral valve disease, bicuspid aortic valves
    3) TAVR shorter recovery period, shorter hospital stay, disadvantages may include durability, and maybe a higher need for pacemaker.
  • 5yr
    1. As always, we wait for the clinical triggers of CHF, angina, syncope, or a drop in LVEF on echo.
    2. As time goes on, almost all patients will be TAVR candidates unless folks are super young and don't want a re-do surgery OR other surgery is needed.
    3. We don't have very long term outcomes from TAVR; there is a risk for pacer need, and they may not be as durable -- but valve in valve may make some of this moot.
  • 5yr
    1. At present, we wait for development of some symptoms, even if subtle. I expect in the future we will refer for valve intervention when stenosis is severe, even if asymptomatic.
    2. At this point, SAVR only preferred in very young patients, or in those with surgical CAD.
    3. Among TAVR advantages are much lower complication rate, much shorter hospitalization and recovery period. Disadvantages to TAVR include less durable valve (vs mechanical SAVR), less long term follow up data.
  • 5yr
    1. Age is the most important factor. I have an intermediate risk 50-something year old that I'm going to push for SAVR. If that patient were 70+, TAVR would be the immediate choice. In between is hard.

    2. The data would suggest that TAVR is potentially superior to SAVR (at least with an Edwards valve) for all comers. That said, anyone over 65 will get TAVR at our institution.

    3. Advantages are less invasiveness, no need to intubate, and early discharge; downsides are "potentially" less durability.
  • 5yr
    1. Age is the most important factor. I have an intermediate risk 50-something year old that I'm going to push for SAVR. If that patient were 70+, TAVR would be the immediate choice. In between is hard.

    2. The data would suggest that TAVR is potentially superior to SAVR (at least with an Edwards valve) for all comers. That said, anyone over 65 will get TAVR at our institution.

    3. Advantages are less invasiveness, no need to intubate, and early discharge; downsides are "potentially" less durability.
  • 5yr
    1. Age is the most important factor. I have an intermediate risk 50-something year old that I'm going to push for SAVR. If that patient were 70+, TAVR would be the immediate choice. In between is hard.

    2. The data would suggest that TAVR is potentially superior to SAVR (at least with an Edwards valve) for all comers. That said, anyone over 65 will get TAVR at our institution.

    3. Advantages are less invasiveness, no need to intubate, and early discharge; downsides are "potentially" less durability.
  • 5yr
    1. Age is the most important factor. I have an intermediate risk 50-something year old that I'm going to push for SAVR. If that patient were 70+, TAVR would be the immediate choice. In between is hard.

    2. The data would suggest that TAVR is potentially superior to SAVR (at least with an Edwards valve) for all comers. That said, anyone over 65 will get TAVR at our institution.

    3. Advantages are less invasiveness, no need to intubate, and early discharge; downsides are "potentially" less durability.
  • 5yr
    1. I tend to be rather aggressive about referring people for valve replacement before they develop symptoms--as soon as valve gradients reach the severe range. If they are close but not quite in the severe range or I am not convinced AS is severe I will sometimes put them on the treadmill to assess true exercise capacity and re-assess gradients post exercise.
    2. TAVR is more or less the standard of care now in my area, except in quite young patients who will definitely need another valve in their lifetime and/or those who do not wish to have a mechanical valve. Obviously in people with prior bypass I am always hopeful TAVR will be suitable.
    3. TAVR: shorter recovery time, avoids complications of sternotomy (particularly a plus in patients with prior open heart history) and less risky with aortopathy. Disadvantages in my mind are still lack of very-long-term follow up and that AI is not always dealt with as well as pure AS.
  • 5yr
    1. I tend to be rather aggressive about referring people for valve replacement before they develop symptoms--as soon as valve gradients reach the severe range. If they are close but not quite in the severe range or I am not convinced AS is severe I will sometimes put them on the treadmill to assess true exercise capacity and re-assess gradients post exercise.
    2. TAVR is more or less the standard of care now in my area, except in quite young patients who will definitely need another valve in their lifetime and/or those who do not wish to have a mechanical valve. Obviously in people with prior bypass I am always hopeful TAVR will be suitable.
    3. TAVR: shorter recovery time, avoids complications of sternotomy (particularly a plus in patients with prior open heart history) and less risky with aortopathy. Disadvantages in my mind are still lack of very-long-term follow up and that AI is not always dealt with as well as pure AS.
  • 5yr
    1. I tend to be rather aggressive about referring people for valve replacement before they develop symptoms--as soon as valve gradients reach the severe range. If they are close but not quite in the severe range or I am not convinced AS is severe I will sometimes put them on the treadmill to assess true exercise capacity and re-assess gradients post exercise.
    2. TAVR is more or less the standard of care now in my area, except in quite young patients who will definitely need another valve in their lifetime and/or those who do not wish to have a mechanical valve. Obviously in people with prior bypass I am always hopeful TAVR will be suitable.
    3. TAVR: shorter recovery time, avoids complications of sternotomy (particularly a plus in patients with prior open heart history) and less risky with aortopathy. Disadvantages in my mind are still lack of very-long-term follow up and that AI is not always dealt with as well as pure AS.
  • 5yr
    1. I tend to be rather aggressive about referring people for valve replacement before they develop symptoms--as soon as valve gradients reach the severe range. If they are close but not quite in the severe range or I am not convinced AS is severe I will sometimes put them on the treadmill to assess true exercise capacity and re-assess gradients post exercise.
    2. TAVR is more or less the standard of care now in my area, except in quite young patients who will definitely need another valve in their lifetime and/or those who do not wish to have a mechanical valve. Obviously in people with prior bypass I am always hopeful TAVR will be suitable.
    3. TAVR: shorter recovery time, avoids complications of sternotomy (particularly a plus in patients with prior open heart history) and less risky with aortopathy. Disadvantages in my mind are still lack of very-long-term follow up and that AI is not always dealt with as well as pure AS.

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