Propensity-matched Comparison Of Minimally Invasive Sutureless Aortic Valve Replacement Versus Transcatheter Treatment In Elderly Patients
Marie Lamberigts1, Filip Rega2, Peter Verbrugghe2, Christophe Dubois2, Bart Meuris2.
1KU Leuven, Leuven, Belgium, 2UZ Leuven, Leuven, Belgium.
BACKGROUND: Recent guidelines favor transcatheter treatment (TAVI) over surgery for aortic valve stenosis above the age of 75y. In Belgium, TAVI reimbursement is limited, resulting in continued referrals for surgery even in elderly patients. All of these patients receive a sutureless Perceval valve (Su-AVR) to shorten the surgical procedure and to facilitate minimal access approach. The aim of this study was to compare short-term outcome of both procedures using propensity matching.
METHODS: All minimally invasive single-valve procedures between 10/2017 and 12/2019 were reviewed, resulting in 107 Su-AVR and 127 TAVI cases done in our institution. Urgent/emergent operations or endocarditis cases were excluded for the surgical procedures and only transfemoral TAVI`s were included. To limit potential confounders, a nearest neighbor propensity score matching was performed in R studio, providing 38 pairs of matched patients. The matched groups were compared by paired t-tests or Wilcoxon signed rank tests for continuous and McNemar tests for categorical variables.
RESULTS: : Age and EuroSCORE II levels (matched cohorts) were 82.4 ± 5.3y and 3.6 (IQR: 2.3 - 4.4) in sutureless AVR, 81.8 ± 6.6y and 3.2 (IQR: 2.3 - 4.9) in TAVI, respectively. All major outcome parameters are listed in Table 1. Within the matched cohort, early mortality and stroke rates were lower in Su-AVR but not significantly different. Discharge echocardiographic parameters showed similar gradients and effective orifice area (EOA) values, with a lower gradients in TAVI (unmatched cohort). TAVI carries a higher risk for any paravalvular leakage (p=0.109, while significant in the unmatched cohort) and higher need for postoperative pacemaker placement (Su-AVR: 2.6% versus TAVI: 21.1%, p=0.016).
CONCLUSIONS:Even in elderly patients, surgical aortic valve replacement using minimal access and a sutureless prosthesis results in a safe procedure, with low rates of major adverse events and good hemodynamics. TAVI offers similar global outcome, with low gradients, but is associated with more paravalvular leakage and higher pacemaker need.
Legend: Data presented as median (interquartile range) or n (%), abbreviations: PPI: permanent pacemaker implantation, (i)EOA: (indexed) effective orifice area, PVL: paravalvular leakage.
| Unmatched Su-AVR (N = 107) | Unmatched TAVR (N = 127) | p-value | Matched Su-AVR (N = 38) | Matched TAVR (N = 38) | p-value | |
| 30-day mortality | 1 (0.9) | 7 (5.5) | 0.074 | 0 (0) | 3 (7.9) | 0.250 |
| Stroke | 2 (1.9) | 8 (6.3) | 0.115 | 2 (5.3) | 4 (10.5) | 0.688 |
| PPI at 30 days | 7 (6.5) | 19 (15.0) | 0.041 | 1 (2.6) | 8 (21.1) | 0.016 |
| Discharge peak gradient (mmHg) | 23 (18 - 32) | 19 (13 - 26) | < 0.001 | 21 (18 - 28) | 22 (15 - 27) | 0.471 |
| Discharge mean gradient (mmHg) | 13 (10 - 17) | 11 (7 - 15) | 0.007 | 12 (10 - 16.5) | 12 (9 - 16) | 0.205 |
| Discharge EOA (cm²) | 1.6 (1.3 - 2.1) | 1.8 (1.4 - 2.1) | 0.144 | 1.6 (1.2 - 2.2) | 1.7 (1.5 - 2.2) | 0.389 |
| Discharge iEOA | 0.9 (0.7 - 1.1) | 0.9 (0.8 - 1.2) | 0.156 | 0.9 (0.7 - 1.2) | 0.9 (0.8 - 1.2) | 0.501 |
| Discharge PVL (>1/4) | 0 (0) | 13 (10.2) | < 0.001 | 0 (0) | 3 (7.9) | 0.250 |
| Discharge PVL (any) | 6 (5.6) | 38 (29.9) | < 0.001 | 2 (5.3) | 8 (21.1) | 0.109 |
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