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J Am Coll Cardiol. 2014 Mar 11;63(9):901-11. doi: 10.1016/j.jacc.2013.08.1641. Epub 2013 Oct 23.

Stratification of outcomes after transcatheter aortic valve replacement according to surgical inoperability for technical versus clinical reasons.

Author information

1
Cedars-Sinai Heart Institute, Los Angeles, California. Electronic address: Raj.Makkar@cshs.org.
2
Cedars-Sinai Heart Institute, Los Angeles, California.
3
Baylor Health Care System, Plano, Texas.
4
Saint-Luke's Mid America Heart Institute, Kansas City, Missouri.
5
Lenox Hill Heart and Vascular Institute, New York, New York.
6
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
7
Emory University, Atlanta, Georgia.
8
Washington Hospital Center, Washington, DC.
9
Cleveland Clinic, Cleveland, Ohio.
10
Intermountain Medical Center, Salt Lake City, Utah.
11
Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve at Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
12
Scripps Clinic and Scripps Translational Science Institute, La Jolla, California.
13
University of Miami Miller School of Medicine, Miami, Florida.
14
St. Paul's Hospital, Vancouver, British Columbia, Canada.

Abstract

OBJECTIVES:

The goal of this study was to examine the impact of reasons for surgical inoperability on outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND:

Patients with severe aortic stenosis may be deemed inoperable due to technical or clinical reasons. The relative impact of each designation on early and late outcomes after TAVR is unclear.

METHODS:

Patients were studied from the inoperable arm (cohort B) of the randomized PARTNER (Placement of Aortic Transcatheter Valve) trial and the nonrandomized continued access registry. Patients were classified according to whether they were classified as technically inoperable (TI) or clinically inoperable (CLI). Reasons for TI included porcelain aorta, previous mediastinal radiation, chest wall deformity, and potential for injury to previous bypass graft on sternal re-entry. Reasons for CLI were systemic factors that were deemed to make survival unlikely.

RESULTS:

Of the 369 patients, 23.0% were considered inoperable for technical reasons alone; the remaining were judged to be CLI. For TI, the most common cause was a porcelain aorta (42%); for CLI, it was multiple comorbidities (48%) and frailty (31%). Quality of life and 2-year mortality were significantly better among TI patients compared with CLI patients (mortality 23.3% vs. 43.8%; p < 0.001). Nonetheless, TAVR led to substantial survival benefits compared with standard therapy in both inoperable cohorts.

CONCLUSIONS:

Patients undergoing TAVR based solely on TI have better survival and quality of life improvements than those who are inoperable due to clinical comorbidities. Both TI and CLI TAVR have significant survival benefit in the context of standard therapy. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).

KEYWORDS:

TAVI; TAVR; inoperable; risk; transcatheter aortic valve

PMID:
24161334
DOI:
10.1016/j.jacc.2013.08.1641
[Indexed for MEDLINE]
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