Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis: a longitudinal study of echocardiography parameters in cohort A of the PARTNER trial (placement of aortic transcatheter valves)

Abstract

Objectives: This study sought to compare echocardiographic findings in patients with critical aortic stenosis following surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR).

Background: The PARTNER (Placement of Aortic Transcatheter Valves) trial randomized patients 1:1 to SAVR or TAVR.

Methods: Echocardiograms were obtained at baseline, discharge, 30 days, 6 months, 1 year, and 2 years after the procedure and analyzed in a core laboratory. For the analysis of post-implantation variables, the first interpretable study (≤6 months) was used.

Results: Both groups showed a decrease in aortic valve gradients and increase in effective orifice area (EOA) (p < 0.0001), which remained stable over 2 years. Compared with SAVR, TAVR resulted in larger indexed EOA (p = 0.038), less prosthesis-patient mismatch (p = 0.019), and more total and paravalvular aortic regurgitation (p < 0.0001). Baseline echocardiographic univariate predictors of death were lower peak transaortic gradient in TAVR patients, and low left ventricular diastolic volume, low stroke volume, and greater severity of mitral regurgitation in SAVR patients. Post-implantation echocardiographic univariate predictors of death were: larger left ventricular diastolic volume, left ventricular systolic volume and EOA, decreased ejection fraction, and greater aortic regurgitation in TAVR patients; and smaller left ventricular systolic and diastolic volumes, low stroke volume, smaller EOA, and prosthesis-patient mismatch in SAVR patients.

Conclusions: Patients randomized to either SAVR or TAVR experience enduring, significant reductions in transaortic gradients and increase in EOA. Compared with SAVR, TAVR patients had higher indexed EOA, lower prosthesis-patient mismatch, and more aortic regurgitation. Univariate predictors of death for the TAVR and SAVR groups differed and might allow future refinement in patient selection. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).

Figure 1

Flow chart of high risk Placement of Aortic Transcatheter (PARTNER) Valves trial. Figure 1A shows the flow chart of patient randomization and follow-up for Cohort A of the PARTNER trial. Figure 1B outlines the intention-to-treat (ITT) and as-treated patient population of Cohort A.

Figure 2

Incidence of prosthesis-patient mismatch. The incidence of prosthesis-patient mismatch (%) in the TAVR and SAVR patient populations is shown. The definition for prosthesis-patient mismatch is as follows: Insignificant is an indexed EOA > 0.85 cm²/m²; Moderate is an indexed EOA of ≥ 0.65 cm²/m² and ≤ 0.85 cm²/m²; Severe is an indexed EOA of < 0.65 cm²/m²

Figure 3

Mitral regurgitation prevalence. The comparison of mitral regurgitation severity in the TAVR versus SAVR patient populations is shown at various follow-up time points. The only significant between-group difference was seen at the 1-year time point with no significant difference at any other time point.

Figure 4

Paravalvular aortic regurgitation incidence. The incidence of paravalvular aortic regurgitation in the TAVR versus SAVR patient populations is shown at various follow-up time points with p-values for between group differences noted. There is a significantly more aortic regurgitation in the TAVR group at every time point.