Introduction The prognosis of untreated severe symptomatic aortic stenosis is poor. Despite this, many patients do not undergo surgical aortic valve replacement (AVR) due to age and/or co-morbidity. Transcatheter aortic valve implantation (TAVI) has emerged as a viable alternative to AVR in such high-risk patients. The aim of this study was to investigate the final treatment and subsequent outcome of patients referred to a single centre for consideration of TAVI.
Methods All patients referred to a single large tertiary cardiac centre for TAVI between January 2008 and November 2009, and who had either undergone definitive treatment, been deemed unsuitable for or declined intervention, or had died prior to treatment, were included. Patients still under assessment were excluded. Procedural risk was assessed using Logistic Euroscore. The primary outcome measure was mortality at last available follow-up.
Results One hundred and twenty-four patients (age 79.9±6.7, 57% male) were included. Mean follow-up period was 254 days (range 0–540 days). Forty-three patients (34.4%) underwent TAVI, 42 with the CoreValve ReValving prosthesis (38 transfemoral; four trans-subclavian), and one with the Edwards Sapien valve (trans-apical). Eight patients (6.5%) had balloon aortic valvuloplasty (BAV), and eight (6.5%) surgical aortic valve replacement (AVR). Sixty-five patients (52.4%) underwent no intervention; 47(37.9%) were deemed unsuitable or declined, while 18 (14.5%) died during assessment or prior to treatment. Patients were unsuitable for TAVI due to severe frailty or co-morbidity (n=16 (34%)), anatomical unsuitability for TAVI (8 (17%)), absence of symptoms (6 (12.8%)), non-severe aortic stenosis (7 (14.9%)), or patient declining intervention (10 (21.3%)). There was no difference in age between any of the groups (AVR 78.6±3.6 yrs, TAVI 79.6±6 yrs,; BAV 79.3±5.1 yrs, no treatment 80±7.6 yrs,). Euroscore was 18.3% in the TAVI patients, significantly higher in the BAV group (29.1%, p=0.035 vs TAVI), non-significantly lower in the AVR patients (11.3%, p=0.11 vs TAVI), and no different in the no treatment group (20.5%, p=0.41 vs TAVI). Thirty-day mortality was 7.0% (3/43) for TAVI, 25% (2/8) for BAV, and 12.5% (1/8) for AVR. Among patients in whom no intervention was undertaken mortality at last follow-up was 41.5% (27/65). Mortality was significantly lower in patients treated by TAVI (6/43 (14.0%), p=0.003 vs no treatment), numerically lower in patients treated by AVR (1/8 (12.5%), p=0.14 vs no treatment), but no different following BAV (3/8 (37.5%), p=1).
Conclusions Mortality in patients with severe symptomatic aortic stenosis referred for consideration of transcatheter aortic valve implantation is extremely high if intervention is not undertaken. Outcome is substantially and significantly improved in patients who undergo TAVI.