• Long-Term Data Back SAVR in Younger and Low-Risk Patients

    Long-term registry data show that 85% of surgical aortic valve replacement (SAVR) patients receiving bioprostheses have low surgical risk, with “substantial” survival – especially in younger, low-risk patients.

    The analysis, published online Monday and in the Nov. 30 issue of the Journal of the American College of Cardiology, reports excellent long-term survival after SAVR – adding that in patients with aortic stenosis aged 60 years or over, for whom both transcatheter aortic valve replacement (TAVR) and SAVR may be considered, the Euro-SCORE identifies 85% of patients who underwent SAVR as having low surgical risk.

    Led by Andreas Martinsson, MD, PhD, from Sahlgrenska University Hospital, Gothenburg, and Gothenburg University, Sweden, the authors commented that such data should be considered in Heart Team discussions, adding that while life expectancy after SAVR in relation to age – both in absolute numbers and in relation to the general population – “has been thoroughly reported,” there remains a lack of data for life expectancy in relation to surgical risk alone and surgical risk combined with chronological age, “despite strong recommendations for assessing these factors during the Heart Team’s decision-making process.”

    “The present national study provides essential perspectives on survival time after SAVR with a bioprosthesis in patients with aortic stenosis at various surgical risks and various age categories,” said Martinsson and colleagues. “This information needs to be considered by the Heart Team when treatment modality is selected in individual patients.”

    Study details

    Martinsson and colleagues analyzed the average survival time in relation to surgical risk and chronological age in 8,353 patients older than 60 years who underwent primary, isolated SAVR with a bioprosthesis in Sweden between 2001 and 2017.

    All patients were risk-stratified before surgery into low, intermediate or high surgical risk using the logistic EuroSCORE (2001-2011) or EuroSCORE II (2012-2017) and divided into age groups. The team estimated median survival time and cumulative 5-year mortality with Kaplan-Meier curves, and Cox regression analysis was used to further determine the importance of age.

    During the 17-year study, there were 7,123 (85.1%) low-risk patients, 942 (11.3%) intermediate-risk patients, and 288 (3.5%) high-risk patients, noted the authors.

    Median survival time was 10.9 years in low-risk patients (95% confidence interval [CI]: 10.6-11.2 years), 7.3 years in intermediate-risk (95% CI: 7.0-7.9 years), and 5.8 years in high-risk patients (95% CI: 5.4-6.5 years). Meanwhile, 5-year cumulative mortality was 16.5% (15.5%-17.4%), 30.7% (27.5%-33.7%), and 43.0%(36.8%-48.7%), respectively.

    In low-risk patients, median survival time ranged from 16.2 years in patients aged 60 to 64 years to 6.1 years in patients aged 85 years or more, noted Martinsson and colleagues, adding that age was associated with 5-year mortality only in low-risk patients (interaction P < 0.001).

     

    “Survival after SAVR was substantial, especially in low-risk patients, but also in higher-risk groups and older patients,” they said.

    “The association between chronological age and 5-year mortality was significant for low-risk patients, whereas no association between age and 5-year mortality in intermediate-risk and high-risk patients was observed.”

    The team noted that longer-term follow-up studies of patients after TAVR are also needed to better inform decisions about choice of intervention for patients with aortic stenosis in various risk strata.

    Making the right choice

    Writing in an accompanying editorial, Natalie Glaser, MD, PhD, from the Stockholm South General Hospital, and Karolinska Institutet, Stockholm, noted that there is an “ongoing debate” on how to choose the optimal treatment modality (SAVR or TAVR) for each individual patient.

    She noted that according to the guidelines from the European Society of Cardiology, patients younger than 75 years with low surgical risk are recommended SAVR, whereas patients older than 75 years or with high surgical risk are recommended TAVR.

    However, guidelines from the American Heart Association/American College of Cardiology suggest SAVR is recommended in patients younger than 65 years or who have a life expectancy of more than 20 years, while transfemoral TAVR is recommended in patients older than 80 years or a life expectancy of less than 10 years.

    “These recommendations leave many patients and physicians with the choice of either SAVR or TAVR, and to choose the optimal treatment modality for each individual patient remains a challenge,” she said.

    The editorialist added that the new analysis “conveys important information … in an era in which the use of TAVR is expanding to include younger and low-risk patients.”

    “It is important to recognize that the current guidelines recommend SAVR to younger and low-risk patients,” she said, noting that the current data confirms excellent long-term survival after SAVR, especially in younger and low-risk patients.

    “Robust evidence that long-term outcomes after TAVR are as good as those after SAVR is needed before TAVR should be recommended for these patients,” she concluded.

    Sources:

    Martinsson A, Nielsen SJ, Milojevic M, et al. Life Expectancy After Surgical Aortic Valve Replacement. J Am Coll Cardiol 2021;78:2147-2157.

    Glaser N. Can TAVR Match the Excellent Survival After SAVR in Younger, Low-Risk Patients? J Am Coll Cardiol 2021;78:2158-2160.

    Image Credit: ungvar – stock.adobe.com

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