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Five-Year Outcomes of Transcatheter or Surgical Aortic-Valve Replacement

Wednesday, February 26, 2020

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Source Name: New England Journal of Medicine


Raj R. Makkar, Vinod H. Thourani, Michael J. Mack, Susheel K. Kodali, Samir Kapadia, John G. Webb, Sung-Han Yoon, Alfredo Trento, Lars G. Svensson, Howard C. Herrmann, Wilson Y. Szeto, D. Craig Miller, et al., for the PARTNER 2 Investigators

Five year results of the PARTNER II trial demonstrated no difference in the risk of stroke or death comparing TAVR to surgical aortic valve replacement among intermediate surgical risk patients.  


The indications for surgery are primarily symptomatic relief. The study appears to intentionally avoid to include a proper discussion on this. Since para-valvular leak, hospital admissions and redo procedure were more with TAVR, it would be safe to conclude TAVR is NOT an indicated procedure in such a cohort. A secondary indication for surgery is survival advantage. This secondary end point is given most of the emphasis. Why? The real world conclusion of the data in this study is that surgery provides a better result for the indications for intervention in aortic stenosis.
this is not surprising given the "focused" end points of this study. I would offer one caveat what about the long term structural durability of a TAVR is when one is dealing with low and intermediate risk patients ? I have been involved with TAVR since 2011. Our program has utilized both Edward's sapien and medtronic platforms. We have also used all currently described access options. Our result's have been great particularly in the original high risk cohart A patients. There is no doubt in my mind that TAVR is a better option in this cohort. That said, I remain concerned for the long term impact on low risk patients. I know that conventional wisdom say's "dont worry, you can have a valve in valve". Really, there is no data to support this. I do not want to be the one who reports his surgical series of total root replacement's for failed valve in valve replacements. Therefore I have begun to offer low risk patients referred to me as part of the TAVR program a durable and safe option ... mechanical aortic valve replacement.Ironic that after 25 years in practise I should come back to this. "what comes around, goes around"

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