EACTSNewsandRecentPublications

TranscatheterAorticValveImplantationhasequivalentsurvivalto
SurgicalAorticValveReplacementatoneyearbutmoreneurologicalevents

The one year results of the first randomised controlled trial comparing transcatheter aortic valve
implantation (TAVI) against surgical aortic valve replacement (AVR) was presented recently at the
American Association of Thoracic Surgery meeting in Philadelphia and has now been published.1
CohortAofthePARTNERtrialrandomised699highriskpatients(meanlogisticEuroscore29)with
symptomaticaorticstenosistoeitherTAVIusingtheEdwardsSAPIENvalve(348patients)orsurgical
AVR (351 patients). Of those randomised to TAVI, 244 were assigned to undergo transfemoral
placementand104totransapicalplacement.Themedianfollowupwas1.4years.

Initsintentiontotreatanalysis,therateofdeathfromanycauseat30dayswasslightlyhigherin
the surgical AVR group although not significantly so (TAVI: 3.4%, AVR 6.5%; p=0.07) but had
equalisedatoneyear(TAVI:24.2%,AVR26.8%;p=0.44).Therateofallneurologicalevents(strokes
and transient ischaemic attacks) was higher in the TAVI group at 30 days (TAVI: 5.5%, AVR: 2.4%;
p=0.04)andatoneyear(TAVI:8.3%,AVR:4.3%;p=0.04).Therateofmajorstrokesweresimilarin
thetwogroupsat30days(TAVI:3.8%,AVR:2.1%;p=0.20)butwerehigherintheTAVIgroupatone
yearalthoughnotsignificantlyso(TAVI:5.1%,AVR:2.4%;p=0.07).At30days,theTAVIgrouphad
morevascularcomplications(TAVI:11.0%,AVR:3.2%;p<0.001)butlessmajorbleeding(TAVI:9.3%,
AVR: 19.5%; p<0.001) and atrial fibrillation (TAVI 8.6%, AVR: 16.0%; p=0.006). TAVI patients had a
shorter hospital stay (3 days versus 5 days, p<0.001), and recovered faster than surgical AVR
patients, with more patients in NYHA class I and II at 30 days and a better six minute walk test
(p<0.001).However,thesehadequalisedbyoneyear.Atoneyear,TAVIhadlowermeangradients
compared to surgical AVR (10.2 4.3 mmHg vs 11.5 5.4 mmHg, p=0.008) and larger effective
orificeareas(1.590.48cm2 vs1.440.47cm2,p=0.002)butmorefrequentmoderateorsevere
paravalvularregurgitation(6.8%vs1.9%,p<0.001).

Inanaccompanyingeditorial,DrHartzellSchaffcommentedthattheavoidanceofasternotomyby
transfemoral or transapical aortic valve implantation appears to come at the price of some
potentiallyseriousvascularandtechnicalcomplicationsandincreasedhazardsofembolicstrokeand
paravalvular leakage.2 Dr Schaff attributes the higher rate of neurological events with TAVI to
calcificatheroscleroticemboliduringcatheteranddevicemanipulationofastenoticaorticvalve.

The one year results of cohort A of the PARTNER trial are nonetheless encouraging, and with
increased experience and further improvement of the device, the results of TAVI are likely to
improve.ThelongtermdurabilityofTAVIis,however,awaited.

K.M.JohnChanFRCSCTh,JohnR.PepperFRCS

12June2011
 EACTSNewsandRecentPublications

REFERENCE

1. Smith, CR, et al. Transcatheter versus surgical aortic valve replacement in high risk patients. N
EnglJMed2011;364(23):21872198

2. Schaff, HV. Transcatheter aortic valve implantation at what price? N Engl J Med
2011;364(23):22562257