Transcatheter Aortic Valve Implantation in the United Kingdom

Abstract

Background-We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality. Methods and Results-Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007)(2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 μmol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P<0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome. Conclusions-We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years.Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors. Since then, another randomized trial 4 and several registries have reported the uptake of TAVI, both valve specific 5-9 and country based.10-15 Nevertheless, there is still a paucity of data relating to long-term outcomes. Here, we assess the patterns of changing indications, clinical characteristics, procedural details, and outcomes from the UK TAVI registry, which has recorded information for every single patient treated by TAVI, amounting to a total of 3980 procedures by the end of 2012. Clinical Perspective on p 1190Methods TAVI was first performed in the United Kingdom in 2007, and by December 2012, 33 centers were active TAVI centers. The early development of UK TAVI up to 2009 has been described. 15 Patient eligibility for a procedure was decided in each center by a multidisciplinary team composed of interventional cardiologists, imaging cardiologists, cardiothoracic surgeons, and anesthetists. The main valve technologies available were the Edwards Sapien and later the Sapien XT, as well as the Medtronic CoreValve. A transfemoral approach was the default strategy for all patients. For those treated with the Medtronic CoreValve, there was later expe...

Multimorbidity in Older Adults with Aortic Stenosis

“…(12,34,43,44) Chronic kidney disease is associated with increased mortality after TAVR and surgical AVR. (33,45,46) End-stage renal disease is less common but occurs in 2% of surgical AVRs and up to 4% of patients in the U.S. TAVR registry, where it is associated with a 66% increase in the hazard of 1-year mortality. (34,46) Acute kidney injury after valve replacement is also associated with increased mortality and may occur less commonly after TAVR compared to surgical AVR.…”

“…(13,14,46,52) Many studies have demonstrated that diabetes is associated with increased mortality after surgical AVR or TAVR. (33,53,54) According to a post-hoc analysis of PARTNER trial patients, there was a survival benefit, no increase in stroke, and less renal failure in diabetic patients treated with TAVR compared to surgical AVR. (52) However, this survival benefit with TAVR among diabetic patients was not observed in the CoreValve sub-group analysis.…”

Transcatheter Aortic Valve Implantation in Lower-Risk Patients With Aortic Stenosis

“…26 In the UK TAVI registry, periprocedural stroke was shown as the strongest independent procedural predictor of long-term mortality (hazard ratio, 3.00; P<0.0001). 13 In Placement of Aortic Transcatheter Valves (PARTNER) 1 trial, 25 periprocedural stroke was associated with ≈2-to 6-fold increase in hospital mortality, a 3-to 12-fold increase in mortality at 30-day, and a 2-to 16-fold increase in longterm mortality. 26 However, although periprocedural stroke or transient ischemic attack was more common after TAVI than after SAVR at 30 days (5.5% versus 2.4%; P=0.04), this difference gradually decreased and by 5 years, the difference had dissipated (TAVI, 14.7% versus SAVR, 15.9%).…”

“…Length of in-hospital stay remained unchanged for SAVR, but decreased for TAVI over time. 12 Baseline overall risk remains an important predictor of 30-day mortality 13 and showed, in many studies, a gradual reduction in patients considered for TAVI. 8,14,15 In some series, more than one third of patients routinely treated with TAVI had an intermediate-to-low risk (defined as a Society of Thoracic Surgeons-predicted risk of operative mortality [STS-PROM] ≤8).…”

“…8,14,15 In some series, more than one third of patients routinely treated with TAVI had an intermediate-to-low risk (defined as a Society of Thoracic Surgeons-predicted risk of operative mortality [STS-PROM] ≤8). 8,14 Notwithstanding, even after adjustment for baseline risk or in healthcare systems where the risk profile of enrolled patients remained high over time, long-term outcomes improved 8,13 reflecting the effectiveness of the aforementioned improvements in TAVI-the procedure and the technology. In the US national (STS/American College of Cardiology [ACC] Transcatheter Valve Therapy [TVT]) registry (n=7710 patients), the median calculated STS-PROM was 7% (interquartile range, 5%-11%), with considerable intersite variation (from 1.2% to 17.4%).…”