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Original Investigation |

Outcomes Following Transcatheter Aortic Valve Replacement in the United States

Michael J. Mack, MD1; J. Matthew Brennan, MD, MPH2; Ralph Brindis, MD, MPH3; John Carroll, MD4; Fred Edwards, MD5; Fred Grover, MD4; David Shahian, MD6; E. Murat Tuzcu, MD7; Eric D. Peterson, MD, MPH2; John S. Rumsfeld, MD, PhD4; Kathleen Hewitt, MSN8; Cynthia Shewan, PhD9; Joan Michaels, RN8; Barb Christensen, RN8; Alexander Christian2; Sean O’Brien, PhD2; David Holmes, MD10; for the STS/ACC TVT Registry
[+] Author Affiliations
1Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas
2Duke Clinical Research Institute, Durham, North Carolina
3University of California, San Francisco
4University of Colorado, Denver
5University of Florida, Jacksonville
6Massachusetts General Hospital, Boston
7Cleveland Clinic, Cleveland, Ohio
8American College of Cardiology, Washington, DC
9Society of Thoracic Surgeons, Chicago, Illinois
10Mayo Clinic, Rochester, Minnesota
JAMA. 2013;310(19):2069-2077. doi:10.1001/jama.2013.282043.
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Importance  Transcatheter aortic valve replacement (TAVR) was approved by the US Food and Drug Administration for the treatment of severe, symptomatic aortic stenosis and inoperable status (in 2011) and high-risk but operable status (starting in 2012). A national registry (the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy [STS/ACC TVT] Registry) was initiated to meet a condition for Medicare coverage and also facilitates outcome assessment and comparison with other trials and international registries.

Objective  To report the initial US commercial experience with TAVR.

Design, Setting, and Participants  We obtained results from all eligible US TAVR cases (n=7710) from 224 participating registry hospitals following the Edwards Sapien device commercialization (November 2011–May 2013).

Main Outcomes and Measures  Primary outcomes included all-cause in-hospital mortality and stroke following TAVR. Secondary analyses included procedural complications and outcomes by clinical indication and access site. Device implantation success was defined as successful vascular access, deployment of a single device in the proper anatomic position, appropriate valve function without either moderate or severe AR, and successful retrieval of the delivery system. Thirty-day outcomes are presented for a representative 3133 cases (40.6%) at 114 centers with at least 80% complete follow-up reporting.

Results  The 7710 patients who underwent TAVR included 1559 (20%) cases that were inoperable and 6151 (80%) cases that were high-risk but operable. The median age was 84 years (interquartile range [IQR], 78-88 years); 3783 patients (49%) were women and the median STS predicted risk of mortality was 7% (IQR, 5%-11%). At baseline, 2176 patients (75%) were either not at all satisfied (1297 patients [45%]) or mostly dissatisfied (879 patients [30%]) with their symptom status; 2198 (72%) had a 5-m walk time longer than 6 seconds (slow gait speed). The most common vascular access approach was transfemoral (4972 patients [64%]), followed by transapical (2197 patients [29%]) and other alternative approaches (536 patients [7%]); successful device implantation occurred in 7069 patients (92%; 95% CI, 91%-92%). The observed incidence of in-hospital mortality was 5.5% (95% CI, 5.0%-6.1%). Other major complications included stroke (2.0%; 95% CI, 1.7%-2.4%), dialysis-dependent renal failure (1.9%; 95% CI, 1.6%-2.2%), and major vascular injury (6.4%; 95% CI, 5.8%-6.9%). Median hospital stay was 6 days (IQR, 4-10 days), with 4613 (63%) discharged home. Among patients with available follow-up at 30 days (n=3133), the incidence of mortality was 7.6% (95% CI, 6.7%-8.6%) (noncardiovascular cause, 52%); a stroke had occurred in 2.8% (95% CI, 2.3%-3.5%), new dialysis in 2.5% (95% CI, 2.0%-3.1%), and reintervention in 0.5% (95% CI, 0.3%-0.8%).

Conclusions and Relevance  Among patients undergoing TAVR at US centers in the STS/ACC TVT Registry, device implantation success was achieved in 92% of cases, the overall in-hospital mortality rate was 5.5%, and the stroke rate was 2.0%. Although these postmarket US approval findings are comparable with prior published trial data and international experience, long-term follow-up is essential to assess continued efficacy and safety.

Trial Registration  clinicaltrials.gov Identifier: NCT01737528

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Figure.
Center-Level Median STS PROM by Reported TAVR Case Volume (n=182 Centers)

STS indicates Society of Thoracic Surgeons; PROM, predicted risk of operative mortality; TAVR, transcatheter aortic valve replacement. In the box-and-whisker plots, the middle line is the median, the top and bottom of the box indicate the interquartile range, and the error bars are minimum and maximum values excluding outliers.

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