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Self-Expanding Transcatheter Aortic Valve Replacement or Surgical Valve Replacement in High-Risk Patients: 5-Year Outcomes.

Research paper by Thomas G TG Gleason, Michael J MJ Reardon, Jeffrey J JJ Popma, G Michael GM Deeb, Steven J SJ Yakubov, Joon S JS Lee, Neal S NS Kleiman, Stan S Chetcuti, James B JB Hermiller, John J Heiser, William W Merhi, George L GL Zorn, Peter P Tadros, Newell N Robinson, George G Petrossian, et al.

Indexed on: 27 Sep '18Published on: 27 Sep '18Published in: JACC (Journal of the American College of Cardiology)



Abstract

The CoreValve US Pivotal High Risk Trial was the first randomized trial to show superior 1-year mortality of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) among high operative mortality-risk patients. The authors sought to compare TAVR to SAVR for mid-term 5-year outcomes of safety, performance, and durability. Surgical high-risk patients were randomized (1:1) to TAVR with the self-expanding bioprosthesis or SAVR. VARC-1 (Valve Academic Research Consortium I) definitions were applied. Severe hemodynamic structural valve deterioration was defined as a mean gradient ≥40 mm Hg or a change in gradient ≥20 mm Hg or new severe aortic regurgitation. Five-year follow-up was planned. A total of 797 patients were randomized at 45 U.S. centers, of whom 750 underwent an attempted implant (TAVR = 391, SAVR = 359). The overall mean age was 83 years, and the STS score was 7.4%. All-cause mortality rates at 5 years were 55.3% for TAVR and 55.4% for SAVR. Subgroup analysis showed no differences in mortality. Major stroke rates were 12.3% for TAVR and 13.2% for SAVR. Mean aortic valve gradients were 7.1 ± 3.6 mm Hg for TAVR and 10.9 ± 5.7 mm Hg for SAVR. No clinically significant valve thrombosis was observed. Freedom from severe SVD was 99.2% for TAVR and 98.3% for SAVR (p = 0.32), and freedom from valve reintervention was 97.0% for TAVR and 98.9% for SAVR (p = 0.04). A permanent pacemaker was implanted in 33.0% of TAVR and 19.8% of SAVR patients at 5 years. This study shows similar mid-term survival and stroke rates in high-risk patients following TAVR or SAVR. Severe structural valve deterioration and valve reinterventions were uncommon.(Medtronic CoreValve U.S. Pivotal Trial; NCT01240902). Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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