Long‐Term Outcomes After Transcatheter and Surgical Aortic Valve Replacement in Patients With Cirrhosis: A Guide for the Hepatologist

Abstract

Background and Aims Hepatologists often determine whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is preferred for patients with cirrhosis and severe aortic stenosis. The goal of this cohort study is to compare outcomes following TAVR and SAVR in patients with cirrhosis to inform the preferred intervention. Approach and Results Prospectively collected data on 105 consecutive patients with cirrhosis and aortic stenosis who underwent TAVR (n = 55) or SAVR (n = 50) between 2008 and 2016 were reviewed retrospectively. Two control groups were included: 2,680 patients without cirrhosis undergoing TAVR and SAVR and 17 patients with cirrhosis who received medical therapy alone. Among the 105 patients with cirrhosis, the median Society of Thoracic Surgeons score was 3.8% (1.5, 6.9), and the median Model for End‐Stage Liver Disease (MELD) score was 11.6 (9.4, 14.0). The TAVR group had similar in‐hospital (1.8% vs. 2.0%) and 30‐day mortality (3.6% vs. 4.2%) as the SAVR group. During the median follow‐up of 3.8 years (95% confidence interval, 3.0‐6.9), there were 63 (60%) deaths. MELD score (adjusted hazard ratio, 1.13; 95% confidence interval, 1.05‐1.21; P = 0.002) was an independent predictor of long‐term survival. In the subgroup of patients with MELD score <12, the TAVR group had reduced survival compared with the SAVR group (median survival of 2.8 vs. 4.4 years; P = 0.047). However, in those with MELD score ≥12, survival after TAVR, SAVR, and medical therapy was similar (1.3 vs. 2.1 vs. 1.6 years, respectively; P = 0.53). Conclusion In select patients with cirrhosis, both TAVR and SAVR have acceptable and comparable short‐term outcomes. MELD score, but not Society of Thoracic Surgeons score, independently predicts long‐term survival after TAVR and SAVR. For patients with MELD score <12, SAVR is a preferred procedure; however, neither procedure appears superior to medical therapy in patients with MELD score ≥12.

The clinical impact of chronic liver disease in patients undergoing transcatheter and surgical aortic valve replacement: Systematic analysis of the 2011–2017 US hospital database

“…For circumstances in which TAVR cannot be performed, 50–52 surgical risks of SAVR in CLD patients, even in the absence of active decompensation, must be rigorously evaluated 53 . Patients must be screened early for impaired liver synthetic, metabolic, and detoxification functions in order to minimize postoperative liver‐induced complications as well as respiratory comorbidities.…”

“…Patients must be screened early for impaired liver synthetic, metabolic, and detoxification functions in order to minimize postoperative liver‐induced complications as well as respiratory comorbidities. Postoperatively, patients that have undergone SAVR should be closely monitored for signs of liver decompensation with emphasis on patient hemostasis, metabolic, and respiratory changes to prevent medically significant complications that can potentially lead to patient death 49–54 …”

Surgical Risk Assessment in Patients with Chronic Liver Diseases

“…46 In carefully selected patients, cardiac surgery followed by liver transplantation or rarely liver transplant before cardiac surgery has been reported but experience is very limited. 45,50,51 Coronary angiography and cardiac catheterization appear safe in patients with cirrhosis. 5…”

Approach to the patient with decompensated cirrhosis and aortic stenosis during liver transplantation evaluation

“…Peeraphatdit et al compared TAVI against SAVR in 105 patients with aortic valve stenosis and cirrhosis between 2008 and 2016. [ 33 ] Overall, the median MELD score was 12. There was no difference in terms of in‐hospital or 30‐day mortality rates between the TAVI and SAVR groups; however, those who underwent TAVI required fewer transfusions and had shorter lengths of stay.…”