title: Clinical outcomes of patients with severe aortic stenosis at increased surgical risk according to treatment modality.
abstract: OBJECTIVE
  The aim of this study was to assess the role of transcatheter aortic valve implantation (TAVI) compared with medical treatment (MT) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) at increased surgical risk.
  
  
  BACKGROUND
  Elderly patients with comorbidities are at considerable risk for SAVR.
  
  
  METHODS
  Since July 2007, 442 patients with severe AS (age: 81.7 ± 6.0 years, mean logistic European System for Cardiac Operative Risk Evaluation: 22.3 ± 14.6%) underwent treatment allocation to MT (n = 78), SAVR (n = 107), or TAVI (n = 257) on the basis of a comprehensive evaluation protocol as part of a prospective registry.
  
  
  RESULTS
  Baseline clinical characteristics were similar among patients allocated to MT and TAVI, whereas patients allocated to SAVR were younger (p < 0.001) and had a lower predicted peri-operative risk (p < 0.001). Unadjusted rates of all-cause mortality at 30 months were lower for SAVR (22.4%) and TAVI (22.6%) compared with MT (61.5%, p < 0.001). Adjusted hazard ratios for death were 0.51 (95% confidence interval: 0.30 to 0.87) for SAVR compared with MT and 0.38 (95% confidence interval: 0.25 to 0.58) for TAVI compared with MT. Medical treatment (<0.001), older age (>80 years, p = 0.01), peripheral vascular disease (<0.001), and atrial fibrillation (p = 0.04) were significantly associated with all-cause mortality at 30 months in the multivariate analysis. At 1 year, more patients undergoing SAVR (92.3%) or TAVI (93.2%) had New York Heart Association functional class I/II as compared with patients with MT (70.8%, p = 0.003).
  
  
  CONCLUSIONS
  Among patients with severe AS with increased surgical risk, SAVR and TAVI improve survival and symptoms compared with MT. Clinical outcomes of TAVI and SAVR seem similar among carefully selected patients with severe symptomatic AS at increased risk.
authors.affiliation: Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Wenaweser
authors.forename: Thomas
authors.initials: T
authors.lastname: Pilgrim
authors.forename: Alexander
authors.initials: A
authors.lastname: Kadner
authors.forename: Christoph
authors.initials: C
authors.lastname: Huber
authors.forename: Stefan
authors.initials: S
authors.lastname: Stortecky
authors.forename: Lutz
authors.initials: L
authors.lastname: Buellesfeld
authors.forename: Ahmed A
authors.initials: AA
authors.lastname: Khattab
authors.forename: Fabienne
authors.initials: F
authors.lastname: Meuli
authors.forename: Nadja
authors.initials: N
authors.lastname: Roth
authors.forename: Balthasar
authors.initials: B
authors.lastname: Eberle
authors.forename: Gabor
authors.initials: G
authors.lastname: Erdös
authors.forename: Henriette
authors.initials: H
authors.lastname: Brinks
authors.forename: Bindu
authors.initials: B
authors.lastname: Kalesan
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meier
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
authors.forename: Thierry
authors.initials: T
authors.lastname: Carrel
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001281:Atrial Fibrillation / Q000453:epidemiology* / Q000209:etiology; D006328:Cardiac Catheterization / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012720:Severity of Illness Index; D013557:Switzerland / Q000453:epidemiology; D016896:Treatment Outcome