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TAVR matches surgery in intermediate-risk patients

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A game changer for intermediate-risk patients

Registries of patients who have undergone transcatheter aortic-valve replacement in Europe and the United States show that this procedure has already been frequently used in selected patients with Society of Thoracic Surgeons operative-risk scores of 4%-8%. Even though regulatory approval specifies using the procedure in high-risk patients with risk scores of at least 8%, the labeling leaves the decision of which patients are at high risk up to local heart teams, and factors other than the risk score play into a patient’s overall risk assessment including frailty and comorbidities.

Despite the prior experience using TAVR in patients with STS risk scores of 4%-8% the results of PARTNER 2A are a game changer because they come from a prospective, randomized, controlled trial.

The PARTNER 2A results are also notable because this is the second randomized trial (in addition to the CoreValve high-risk trial) with results that show or suggest that transcatheter aortic-valve replacement (TAVR) produces better outcomes than surgery, especially in patients who undergo TAVR via a transfemoral approach. Other notable advantages of TAVR over surgery seen in PARTNER 2A include substantial reductions in disabling or life-threatening bleeding events and in new-onset atrial fibrillation, a statistically significant reduction in acute kidney injury, and no significant difference in the incidence of disabling strokes. In the past, we expected stroke rates to be higher with TAVR, but in PARTNER 2A, with neurologists adjudicating the strokes, we saw no difference in the TAVR and surgical stroke rates, a finding that was probably unexpected for many people.

Dr. Ajay J. Kirtane

The patients enrolled in PARTNER 2A were clearly at lower risk for all-cause mortality than the patients enrolled in the earlier TAVR trials. The operative risk score is just one of several ways to estimate patient risk. The data collected in PARTNER 2A provide a robust resource for finding new, additional ways to assess patients who are at intermediate risk and to match patients seen during routine practice to those who entered this trial.

Dr. Ajay J. Kirtane is an interventional cardiologist and director of the coronary catheterization laboratory at New York–Presbyterian/Columbia University in New York. He was a coinvestigator on prior Sapien TAVR studies but did not participate in PARTNER 2. His institution has received research support from Edwards and from Boston Scientific. He made these comments in an interview.




CHICAGO – Transcatheter aortic-valve replacement performed as well as surgical-valve replacement in patients with an intermediate mortality risk in a prospective, randomized trial with more than 2,000 patients followed for 2 years, the first randomized trial to compare the efficacy and safety of transcatheter aortic-valve replacement against surgical replacement in patients who did not have a high mortality risk.

The results “support TAVR [transcatheter aortic-valve replacement] as an alternative to surgery in intermediate-risk patients similar to those included in this trial,” said Dr. Craig R. Smith at the annual meeting of the American College of Cardiology. The findings from the Placement of Aortic Transcatheter Valves (PARTNER) 2 cohort A trial “will increase use of TAVR,” predicted Dr. Smith, professor and chairman of surgery at New York–Presbyterian Hospital/Columbia University in New York.

Dr. Craig R. Smith Mitchel L. Zoler/Frontline Medical News

Dr. Craig R. Smith

Until now, TAVR had been compared with surgical aortic-valve replacement in two prospective, randomized trials that both enrolled either high-risk or inoperable patients with severe aortic stenosis, the PARTNER 1 trial that tested the original Sapien TAVR system, and the U.S. CoreValve High-Risk Study that tested the original CoreValve system (often now called CoreValve classic). The average Society of Thoracic Surgeons (STS) operative risk score of high-risk patients enrolled in PARTNER 1 was 11.8%, and the average risk score in patients enrolled in the CoreValve study was 7.3%. In contrast, the design of PARTNER 2A specified that enrolled patients have a STS risk score of 4%-8%, a criterion actually met by 81% of the enrolled patients, and the average STS risk score of all patients enrolled in PARTNER 2A was 5.8%.

Although U.S. labeling for both the Sapien valve and its later iterations, Sapien XT and S3, and for CoreValve and its later iteration, Evolut R, specify that treated patients should have a STS risk score of at least 8%, the labeling also gives the heart teams that perform TAVR the latitude to treat patients with risk scores below 8% when the heart teams identify other patient factors that confer high risk such as frailty or comorbidities. U.S. and European TAVR registries have documented that many patients with STS risk scores below 8% have undergone TAVR since these systems received regulatory approval. The new results from PARTNER 2A may change that by leading to revised labeling that cuts the STS risk-score threshold.

“These findings might lead to a labeling change that would avoid a lot of the patient-evaluation gymnastics that have been used to justify” TAVR treatment, noted Dr. Smith. New labeling like this “would sanction what is already going on” in terms of which patients undergo TAVR.

Others who heard these results at the meeting agreed they were an important milestone in TAVR development and its expanding use.

Dr. David R. Holmes, Jr. Mitchel L. Zoler/Frontline Medical News

Dr. David R. Holmes, Jr.

The new results “make a huge difference,” commented Dr. David R. Holmes Jr., an interventional cardiologist and professor at the Mayo Clinic in Rochester, Minn. “We base many of our guidelines on the results from randomized, controlled trials. It’s true that there are reports of lower-risk patients undergoing TAVR, but we now have results from a well-designed trial with well-controlled and adjudicated endpoints that documents the safety and efficacy of TAVR in intermediate-risk patients,” Dr. Holmes said in an interview.

“The results will have a very important influence on the choice between TAVR and surgery,” commented Dr. Duane S. Pinto, an interventional cardiologist at Beth Israel Deaconess Medical Center in Boston. “It validates the strategy” of using TAVR in patients with a risk score of 4%-8%. “TAVR has already been used in these patients, but these results validate this, especially when used in a transfemoral approach,” Dr. Pinto said in an interview.

Dr. Duane S. Pinto

Dr. Duane S. Pinto

One aspect of PARTNER 2A that received a lot of discussion at the meeting was whether enrolled patients could appropriately be characterized as “intermediate” in their risk level. Although their average STS risk score of 5.8% fell squarely within the target range specified for the study, they averaged 82 years old, and other clinical features at baseline suggested a higher risk population. The published report of the PARTNER 2A results that appeared online concurrent with Dr. Smith’s report at the meeting (New Engl J Med 2016;doi:10.1056/NEJMoa1514616) acknowledged that STS risk scores of 4%-8% place the enrolled patients into the upper 20% for risk of all U.S. patients who undergo surgical aortic-valve replacement

“I would characterize the enrolled patients as ‘less high risk’ rather than intermediate risk,” said Dr. Pinto.


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