title: The impact of the development of transcatheter aortic valve implantation on the management of severe aortic stenosis in high-risk patients: treatment strategies and outcome.
abstract: OBJECTIVE
  Transcatheter aortic valve implantation (TAVI) has reoriented the treatment of aortic stenosis (AS) for high-risk patients. Little is known about late outcome after TAVI, surgical aortic valve replacement (AVR) or medical treatment in a single centre. We report patients' characteristics, early and 6-year survival rates after the three therapeutic strategies, and the evolution over time. We also analysed predictive factors of mortality after TAVI or surgical AVR.
  
  
  METHODS
  Between October 2006 and December 2010, 478 high-risk consecutive patients were referred for severe symptomatic AS. After Heart Team evaluation, 253 underwent a TAVI, 102 a surgical AVR and 123 medical treatment including 33 compassionate percutaneous balloon aortic valvuloplasties (PBAVs). Follow-up was complete in 98% of patients.
  
  
  RESULTS
  Medically treated patients had higher risk scores than the other two groups. They presented a significantly worse survival (P < 0.001), with a 1-year rate of only 30%. The 33 patients who underwent compassionate PBAV presented the lowest survival rate, even lower than patients receiving drug therapy alone. In the TAVI group, patients had more comorbidities than those in the surgical group. There was no difference in 30-day survival rates [91 ± 2% for TAVI and 88 ± 3% for surgical AVR, hazard ratio (HR) for TAVI: 1.37; 95% CI: 0.73-2.58, P = 0.32]. Predictive factors of 30-day mortality were mainly postintervention complications illustrated by higher troponin levels and infection. The 6-year survival rates were 32 ± 4 and 40 ± 6% for TAVI and surgical AVR, respectively (HR for TAVI: 0.71; 95% CI: 0.53-0.97, P = 0.03), but the difference was no longer significant after adjustment on the Charlson comorbidity index (HR: 0.94; 95% CI: 0.68-1.29, P = 0.68). Predictive factors of late mortality were patients' comorbidities for both groups and paraprosthetic aortic regurgitation ≥2/4 for the TAVI group. The number of interventions (TAVI or surgery) increases over years, driven by the number of TAVI procedures without any decrease in surgical AVR.
  
  
  CONCLUSIONS
  In this single-centre study, medically treated patients with severe AS have a higher risk profile than those undergoing surgery or TAVI. Their survival is particularly poor and not improved by compassionate PBAV. When comparing TAVI and surgical AVR, there was no difference in 30-day and 6-year survival rates after adjusting for comorbidities.
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France claire.bouleti@bch.aphp.fr.|DHU Fire, Paris-Diderot University, Paris, France.
authors: Claire
authors: C
authors: Bouleti
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Marion
authors: M
authors: Chauvet
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Guillaume
authors: G
authors: Franchineau
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.|DHU Fire, Paris-Diderot University, Paris, France.|INSERM U1148 Bichat Hospital, Paris, France.
authors: Dominique
authors: D
authors: Himbert
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.|DHU Fire, Paris-Diderot University, Paris, France.|INSERM U1148 Bichat Hospital, Paris, France.|Faculté de Médecine Paris-Diderot University, Paris, France.
authors: Bernard
authors: B
authors: Iung
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Benjamin
authors: B
authors: Alos
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.|DHU Fire, Paris-Diderot University, Paris, France.
authors: Eric
authors: E
authors: Brochet
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.|DHU Fire, Paris-Diderot University, Paris, France.
authors: Marina
authors: M
authors: Urena
authors: Department of Cardiac Surgery, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Walid
authors: W
authors: Ghodbane
authors: INSERM U1148 Bichat Hospital, Paris, France.|Faculté de Médecine Paris-Diderot University, Paris, France.|Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Phalla
authors: P
authors: Ou
authors: Department of Anaesthesiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Sophie
authors: S
authors: Provenchere
authors: DHU Fire, Paris-Diderot University, Paris, France.|Faculté de Médecine Paris-Diderot University, Paris, France.|Department of Cardiac Surgery, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.
authors: Patrick
authors: P
authors: Nataf
authors: Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France.|DHU Fire, Paris-Diderot University, Paris, France.|INSERM U1148 Bichat Hospital, Paris, France.|Faculté de Médecine Paris-Diderot University, Paris, France.
authors: Alec
authors: A
authors: Vahanian
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006350:Heart Valve Prosthesis; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods* / Q000592:standards*
keywords: Aortic stenosis; Percutaneous balloon valvuloplasty; Surgical aortic valve replacement; Transcatheter aortic valve implantation