The Impact of TAVR on Moderate-High Risk SAVR?

E. Norton¹, A. Ward², B. Leshnower³, R. Guyton¹, G. Paone⁴, W. Brent. Keeling¹, J. Miller⁵, M. Halkos¹, K. Grubb^1
1Emory University, Atlanta, Georgia ²Emory University/Grady Memorial Hospital, Atlanta, Georgia ³Emory University School of Medicine, Atlanta, Georgia ⁴Emory University School of Medicine, Charlotte, North Carolina ⁵Emory Saint Joseph's Hospital, CT Surgery, Atlanta, Georgia

Purpose: Transcatheter aortic valve replacement (TAVR) changed aortic valve disease management, and is now approved for all degrees of surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). We sought to evaluate the impact of TAVR on isolated surgical aortic valve replacement (SAVR) among intermediate- and high-surgical risk patients.

Methods: Single center retrospective review of 3861 isolated SAVRs from January 2000 – June 2020 performed at a multisite academic healthcare system with a structural heart center that was established in 2012. A total of 1119 (29%) were intermediate to high surgical risk, as defined by Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) >3% and
Results: The median age of the entire cohort was 76 years and younger in the post-TAVR era (75 vs 76 years, p=0.03). SAVR patients in the post-TAVR era had more comorbidities including hypertension (95% vs 89%, p=0.001), dyslipidemia (88% vs 68%, p< 0.0001), chronic lung disease (47% vs 38%, p=0.005), heart failure (90% vs 70%, p< 0.0001) and less prior aortic valve replacement (5% vs 10%, p=0.004). In the post-TAVR era, a higher proportion of SAVRs were performed for isolated aortic insufficiency (20% vs 14%, p=0.02) and fewer patients had aortic stenosis (79% vs 85%, p=0.01). In the post-TAVR era more SAVRs were performed in the urgent or emergent setting (65% vs 39%, p< 0.0001) and there was increased utilization of bioprosthetic valves (92% vs 87%, p=0.01), larger valves (23 [23,27] vs 23 [21,25], p< 0.0001), and more annular enlargements (5.7% vs 1.4%, p=0.0001). Postoperatively, the post-TAVR era had less blood product transfusion (66% vs 72%, p=0.04), renal failure (1.9% vs 7.6%, p=0.0001), and lower in-hospital mortality (2.3% vs 5.6%, p=0.009).

Conclusion: TAVR has significantly changed the landscape of aortic valve disease management. However, isolated SAVR in intermediate-to-high surgical risk continues to be performed in the TAVR era with excellent outcomes and remains an essential tool in the lifetime management of aortic valve disease.

Identify the source of the funding for this research project: None