Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience.
OBJECTIVE
The aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty.


BACKGROUND
Very few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk.


METHODS
Consecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included.


RESULTS
A total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 +/- 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up.


CONCLUSIONS
A TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes.
Rodés-Cabau
Josep
J
Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada. josep.rodes@criucpq.ulaval.ca
Webb
John G
JG
Cheung
Anson
A
Ye
Jian
J
Dumont
Eric
E
Feindel
Christopher M
CM
Osten
Mark
M
Natarajan
Madhu K
MK
Velianou
James L
JL
Martucci
Giuseppe
G
DeVarennes
Benoît
B
Chisholm
Robert
R
Peterson
Mark D
MD
Lichtenstein
Samuel V
SV
Nietlispach
Fabian
F
Doyle
Daniel
D
DeLarochellière
Robert
R
Teoh
Kevin
K
Chu
Victor
V
Dancea
Adrian
A
Lachapelle
Kevin
K
Cheema
Asim
A
Latter
David
D
Horlick
Eric
E
D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000401:mortality* / Q000601:surgery*; D002170:Canada; D006328:Cardiac Catheterization; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome