High-Risk Patients Referred for Transcatheter Aortic Valve Implantation: Management and Outcomes

Background. Aortic valve replacement (AVR) is the treatment of choice for critical aortic stenosis. Selected patients have not previously been referred for AVR because of excessive risk of mortality and morbidity with surgery. The option of transcatheter aortic valve implantation (TAVI) has increased referral of this high-risk cohort for therapeutic intervention. We report the management and outcomes of these patients. Methods. Patients referred for TAVI from December 2005 to December 2007 were evaluated and followed up for intermediate-term all cause mortality. Patients received medical management, TAVI, conventional AVR, or balloon valvuloplasty (BAV) based on risk profile, hemodynamic and echocardiographic criteria, physician judgment, or patient choice. Patients were compared for demographics, Society of Thoracic Surgeons predicted risk of mortality score, and outcomes after AVR, TAVI, or BAV. Results. One hundred five patients were referred for TAVI during a 24-month period. Fifty-two patients (49.5%) received medical management, 16 (15.2%) conventional AVR, 21 (20.0%) received TAVI, and 16 ( 15.2%) received BAV. Patients were classified as medical management because of physician or patient choice, not meeting TAVI criteria, or underevaluation for a possible procedure. For all patients the average length of follow-up was 159 +/- 147 days. Patients receiving BAV had a Society of Thoracic Surgeons predicted risk of mortality score greater than those having medical management, AVR, or TAVI. Thirty-day mortality was 1 of 16 patients (6.3%) for AVR, 2 of 21 patients (9.5%) with TAVI, 2 of 16 patients (12.5%) for BAV, and 7 of 52 patients (13.5%) for the medical management cohort. Overall mortality during follow-up was 42.3% ( 22 of 52 patients) for medical management, 19.1% ( 4 of 21 patients) for TAVI, 12.5% ( 2 of 16 patients) for AVR, and 37.5% ( 6 of 16 patients) for BAV. Conclusions. The population of patients screened for transcatheter therapy is complex and heterogeneous. Medical management alone demonstrates a high mortality rate, and BAV, although providing transient symptomatic relief, does not favorably impact survival. The majority of referred patients (65.7%), including those that declined intervention, were candidates for some form of valve replacement therapy, either TAVI or AVR. Trans-catheter aortic valve implantation can be performed in appropriately selected patients with good early and immediate-term outcomes.