Appropriate patient selection or health care rationing? Lessons from surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves i trial Read at the 95th Annual Meeting of the American Association for Thoracic Surgery, Seattle, Washington, April 25-29.

Wilson Y. Szeto, Lars G. Svensson, Jeevanantham Rajeswaran, John Ehrlinger, Rakesh M. Suri, Craig R. Smith, Michael Mack, D. Craig Miller, Patrick M. McCarthy, Joseph E. Bavaria, Lawrence H. Cohn, Paul J. Corso, Robert A. Guyton, Vinod H. Thourani, Bruce W. Lytle, Mathew R. Williams, John G. Webb, Samir Kapadia, E. Murat Tuzcu, David J. CohenHartzell V. Schaff, Martin B. Leon, Eugene H. Blackstone*

*Corresponding author for this work

Research output: Contribution to journalArticle

7 Scopus citations

Abstract

Objectives The study objectives were to (1) compare the safety of high-risk surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves (PARTNER) I trial with Society of Thoracic Surgeons national benchmarks; (2) reference intermediate-term survival to that of the US population; and (3) identify subsets of patients for whom aortic valve replacement may be futile, with no survival benefit compared with therapy without aortic valve replacement. Methods From May 2007 to October 2009, 699 patients with high surgical risk, aged 84 ± 6.3 years, were randomized in PARTNER-IA; 313 patients underwent surgical aortic valve replacement. Median follow-up was 2.8 years. Survival for therapy without aortic valve replacement used 181 PARTNER-IB patients. Results Operative mortality was 10.5% (expected 9.3%), stroke 2.6% (expected 3.5%), renal failure 5.8% (expected 12%), sternal wound infection 0.64% (expected 0.33%), and prolonged length of stay 26% (expected 18%). However, calibration of observed events in this relatively small sample was poor. Survival at 1, 2, 3, and 4 years was 75%, 68%, 57%, and 44%, respectively, lower than 90%, 81%, 73%, and 65%, respectively, in the US population, but higher than 53%, 32%, 21%, and 14%, respectively, in patients without aortic valve replacement. Risk factors for death included smaller body mass index, lower albumin, history of cancer, and prosthesis-patient mismatch. Within this high-risk aortic valve replacement group, only the 8% of patients with the poorest risk profiles had estimated 1-year survival less than that of similar patients treated without aortic valve replacement. Conclusions PARTNER selection criteria for surgical aortic valve replacement, with a few caveats, may be more appropriate, realistic indications for surgery than those of the past, reflecting contemporary surgical management of severe aortic stenosis in high-risk patients at experienced sites.

Original languageEnglish (US)
Pages (from-to)557-568.e11
JournalJournal of Thoracic and Cardiovascular Surgery
Volume150
Issue number3
DOIs
StatePublished - Sep 1 2015

Keywords

  • Society of Thoracic Surgeons
  • aortic stenosis
  • aortic valve replacement

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

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    Szeto, W. Y., Svensson, L. G., Rajeswaran, J., Ehrlinger, J., Suri, R. M., Smith, C. R., Mack, M., Miller, D. C., McCarthy, P. M., Bavaria, J. E., Cohn, L. H., Corso, P. J., Guyton, R. A., Thourani, V. H., Lytle, B. W., Williams, M. R., Webb, J. G., Kapadia, S., Tuzcu, E. M., ... Blackstone, E. H. (2015). Appropriate patient selection or health care rationing? Lessons from surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves i trial Read at the 95th Annual Meeting of the American Association for Thoracic Surgery, Seattle, Washington, April 25-29. Journal of Thoracic and Cardiovascular Surgery, 150(3), 557-568.e11. https://doi.org/10.1016/j.jtcvs.2015.05.073