Comparative Outcomes of Surgical and Transcatheter Aortic Valve Replacement for Aortic Stenosis in Nonagenarians

Zack, Chad J.; Alqahtani, Fahad; Kawsara, Akram; Al-Hijji, ‪Mohammed; Amin, Ali Hama; Alkhouli, Mohamad

doi:10.1016/j.amjcard.2016.11.045

Cited by 15 publications

(16 citation statements)

References 11 publications

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“…As deduced from studies reporting results of TAVI in nonagenarians summarized in Table 1, TAVI, as long as it is performed via the transfemoral route, is feasible and relatively safe and effective in this patient subpopulation, albeit at higher risk compared to younger patients, with satisfactory short-and mid-term outcomes, however, long-term data are meagre (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Procedural and 30-day mortality ranges from 0% to 27%, hovering around 10%, stroke risk ranges from 2% to 18% (average 3-4%), bleeding and vascular complications range from 9% to 34% (average ~16%), renal insufficiency ranges from 1% to 10%, while the emerging need for a pacemaker has a wide range depending on the type of valve employed (5-30%) (41).…”

Section: Clinical Outcomesmentioning

confidence: 99%

“…As the cost of TAVI is currently very high and much higher than surgical AVR (45), one may argue that based on the equivalent results presented by some investigators for TAVI and surgical AVR in nonagenarians, referral for AVR in these patients should not be precluded based on age alone (5).…”

Section: Costmentioning

confidence: 99%

“…Other investigators have proposed that in nonagenarians, both TAVI and surgical aortic valve replacement (AVR) can be performed with acceptable inhospital outcomes and that interventional management should not be precluded based on age alone (5).…”

Section: Introductionmentioning

confidence: 99%

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Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

Manolis¹,

Manolis²

2017

Ann. Cardiothorac. Surg.

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A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.

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Section: Clinical Outcomesmentioning

confidence: 99%

Section: Costmentioning

confidence: 99%

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Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

Manolis¹,

Manolis²

2017

Ann. Cardiothorac. Surg.

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“…We also found that there was no difference in in‐hospital mortality among those who underwent transfemoral TAVR compared with SAVR, which is considered the contemporary approach for TAVR . Although a previous analysis of the NIS database compared the in‐hospital outcomes for TAVR versus SAVR in nonagenarians, that analysis was limited until 2013 . In addition, that study utilized the unweighted data which is not adherent to the required practices when conducting complex analyses from the HCUP databases .…”

Section: Discussionmentioning

confidence: 97%

“…Although a previous analysis of the NIS database compared the in‐hospital outcomes for TAVR versus SAVR in nonagenarians, that analysis was limited until 2013 . In addition, that study utilized the unweighted data which is not adherent to the required practices when conducting complex analyses from the HCUP databases . By including 2014, we have added a considerably larger number of patients (i.e., 1,580 patients in the TAVR group in our study as opposed to 315 in the other study) in our analysis.…”

Section: Discussionmentioning

confidence: 99%

In‐hospital outcomes of transcatheter versus surgical aortic valve replacement for nonagenarians

Elgendy

Mahmoud

Elbadawi

et al. 2018

Cathet Cardio Intervent

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Objectives To compare the in‐hospital outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in nonagenarians. Background Data comparing the outcomes of TAVR versus SAVR in nonagenarians are limited. Methods Using the National Inpatient Sample years 2012–2014, hospitalization data were retrieved for subjects aged ≥90 years who underwent TAVR or SAVR for severe aortic stenosis. The incidence of in‐hospital mortality and peri‐procedural outcomes were compared using unadjusted, multivariate logistic regression, and propensity score matched analyses. Results The final cohort included 6,680 records of nonagenarians undergoing aortic valve replacement, among which 5,840 (87.4%) underwent TAVR. There was no difference in the incidence of in‐hospital mortality between both groups in the unadjusted (5.8% versus 6.0% P = 0.95), multivariate (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.35–1.74), and propensity score matched (OR 1.07, 95% CI 0.75–1.51) analyses. In the propensity‐matched analysis, TAVR was associated with a lower incidence of acute kidney injury (OR 0.58, 95% CI 0.47–0.72), post‐operative blood transfusion (OR 0.51, 95% CI 0.43–0.61), a higher likelihood of discharge to home (OR 4.71, 95% 3.44–5.06), and a similar incidence of pacemaker placement (OR 1.16, 95% 0.89–1.53) and stroke (OR 1.34, 0.90–1.99). Conclusions In this nationwide analysis, TAVR was associated with an overall similar incidence of in‐hospital mortality and less morbidity compared with SAVR. These findings suggest that TAVR is effective and safe in nonagenarians.

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Estimating the additional costs per life saved due to transcatheter aortic valve replacement: a secondary data analysis of electronic health records in Germany

et al. 2019

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Aortic stenosis (AS) is the most common valvular heart disease, with a dismal prognosis when untreated. Recommended therapy is surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. Based on a retrospective cohort of isolated SAVR and TAVR procedures performed in Germany in 2015 (N = 17,826), we examine the impact of treatment selection on in-hospital mortality and total in-hospital costs for a variety of at-risk populations. Since patients were not randomized to the two treatment options, the two endpoints in-hospital mortality and reimbursement are analyzed using logistic and linear regression models with 20 predefined patient characteristics as potential confounders. Incremental cost-effectiveness ratios were calculated as a ratio of the risk-adjusted reimbursement and mortality differences with 95% confidence intervals obtained by Fieller's theorem. Our study shows that TF-TAVR is more costly that SAVR and that cost differences between the procedures vary little between patient groups. Results regarding in-hospital mortality are mixed. SAVR is the predominant procedure among younger patients. For patients older than 85 years or at intermediate and higher pre-operative risk TF-TAVR seems to be the treatment of choice. Incremental cost-effectiveness ratios (ICER) are most favorable for patients older than 85 years (ICER €154,839, 95% CI €89,163-€302,862), followed by patients at higher pre-operative risk (ICER €413,745, 95% CI €258,027-€952,273). A hypothetical shift from SAVR towards TF-TAVR among patients at intermediate pre-operative risk is associated with a less favorable ICER (€1,486,118, 95% CI €764,692,323), as the risk-adjusted mortality benefit is relatively small (− 0.97% point), while the additional reimbursement is still eminent (+€14,464). From a German healthcare system payer's perspective, the additional costs per life saved due to TAVR are most favorable for patients older than 85 and/or at higher pre-operative risk.

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Comparative Outcomes of Surgical and Transcatheter Aortic Valve Replacement for Aortic Stenosis in Nonagenarians

Cited by 15 publications

References 11 publications

Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?

In‐hospital outcomes of transcatheter versus surgical aortic valve replacement for nonagenarians

Estimating the additional costs per life saved due to transcatheter aortic valve replacement: a secondary data analysis of electronic health records in Germany

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