title: Improvements in transcatheter aortic valve implantation outcomes in lower surgical risk patients: a glimpse into the future.
abstract: OBJECTIVE
  The purpose of this study was to investigate the evolution of patient selection criteria for transcatheter aortic valve implantation (TAVI) and its impact on clinical outcomes.
  
  
  BACKGROUND
  Anecdotal evidence suggests that patient selection for TAVI is shifting toward lower surgical risk patients. The extent of this shift and its impact on clinical outcomes, however, are currently unknown.
  
  
  METHODS
  We conducted a single-center study that subcategorized TAVI patients into quartiles (Q1 to Q4) defined by enrollment date. These subgroups were subsequently examined for differences in baseline characteristics and 30-day and 6-month mortality rate. The relationship between quartiles and mortality rate was examined using unadjusted and adjusted (for baseline characteristics) Cox proportional hazard models.
  
  
  RESULTS
  Each quartile included 105 patients (n = 420). Compared with Q4 patients, Q1 patients had higher logistic EuroSCORES (25.4 ± 16.1% vs. 17.8 ± 12.0%, p < 0.001), higher Society of Thoracic Surgeons scores (7.1 ± 5.5% vs. 4.8 ± 2.6%, p > 0.001), and higher median N-terminal pro-B-type natriuretic peptide levels (3,495 vs. 1,730 ng/dl, p < 0.046). From Q1 to Q4, the crude 30-day and 6-month mortality rate decreased significantly from 11.4% to 3.8% (unadjusted hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.11 to 1.01; p = 0.053) and from 23.5% to 12.4% (unadjusted HR: 0.49; 95 CI: 0.25 to 0.95; p = 0.07), respectively. After adjustment for baseline characteristics, there were no significant differences between Q1 and Q4 in 30-day mortality rate (adjusted HR ratio: 0.29; 95% CI: 0.08 to 1.08; p = 0.07) and 6-month mortality rate (HR: 0.67; 95% CI: 0.25 to 1.77; p = 0.42).
  
  
  CONCLUSIONS
  The results of this study demonstrate an important paradigm shift toward the selection of lower surgical risk patients for TAVI. Significantly better clinical outcomes can be expected in lower than in higher surgical risk patients undergoing TAVI.
authors.affiliation: German Heart Center, Lazarette Strasse 36, Munich, Germany.
authors.forename: Ruediger
authors.initials: R
authors.lastname: Lange
authors.forename: Sabine
authors.initials: S
authors.lastname: Bleiziffer
authors.forename: Domenico
authors.initials: D
authors.lastname: Mazzitelli
authors.forename: Yacine
authors.initials: Y
authors.lastname: Elhmidi
authors.forename: Anke
authors.initials: A
authors.lastname: Opitz
authors.forename: Marcus
authors.initials: M
authors.lastname: Krane
authors.forename: Marcus-Andre
authors.initials: MA
authors.lastname: Deutsch
authors.forename: Hendrik
authors.initials: H
authors.lastname: Ruge
authors.forename: Gernot
authors.initials: G
authors.lastname: Brockmann
authors.forename: Bernhard
authors.initials: B
authors.lastname: Voss
authors.forename: Christian
authors.initials: C
authors.lastname: Schreiber
authors.forename: Peter
authors.initials: P
authors.lastname: Tassani
authors.forename: Nicolo
authors.initials: N
authors.lastname: Piazza
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods / Q000401:mortality / Q000639:trends*; D005260:Female; D005544:Forecasting; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality / Q000639:trends*; D006801:Humans; D008297:Male; D012307:Risk Factors; D016896:Treatment Outcome