What TAVI Has Done with Us—Impact of Catheter-based Procedures on a Surgical Aortic Valve Program

Objectives: Cardiac surgery continuously is challenged by evolutionary changes of heart medicine in general. Unequalled, this development is reflected by isolated aortic valve surgery. We looked up the development of demographics and technical aspects during a 17-year period.

Methods: All isolated, elective aortic valve procedures from January 2000 until December 2017 were included, finally numbering 6,468 patients. Those consisted of 4,584 conventional surgical aortic valve replacements, completed by 1,884 transcatheter valve procedures, starting in 2008.

Results: In conventional AVR, the mean age slighty increased (66.9 years in 2000 to 68.6 years in 2017; p < 0.01), meanwhile mean body mass index more distinctly increased by 2 points (27.2 in 2000 to 29.2 in 2017). The percentage of minimally invasive procedures raised from 0% in 2000 to 76.48% in 2017, with anterolateral thoracotomy being the most frequent chosen access route (31.4%). As a representative of patient’s comorbidities, the logistic EuroScore constantly decreased from 11.6% (start of recording in 2006) to 6.0% in 2017, with a pronounced effect after establishing a relevant transcatheter valve program in 2008. This likewise translated in improved hospital survival (96.0% in 2008 to 98.1% in 2017; p < 0.01). The number of postoperative complications, such as renal failure, rethoracotomy or stroke remained constantly low during time. A more restrictive use of blood products was recorded (2.8 PRBC in mean in 2000 compared with 0.80 PRBC’s in 2017). Accordingly, the mean ICU-stay decreased, with 22.4% in 2000 to 60.5% of the patients being discharged from ICU within 1 day in 2017. The absolute numbers of surgical AVRs was constant until 2008 (n = 323/year), but then constantly dropping to an annual mean of 250 in the following years. At the same time, TAVR steadily increased from 2008, reaching a stable plateau in 2014 of some 600 procedures a year. In TAVR, the transapical access (25.7% in 2014) was outperformed by the transfemoral route (94.6% in 2017). Mortality in TAVR undulated around 3.5%. Nonetheless, the overall hospital mortality of treated aortic valve stenosis (SAVR and TAVR combined), did not change significantly over time.

Conclusion: The era of one procedure fits all has ended. Nowadays, treatment of aortic valve disease is complex and characterized by multiple possible techniques and valve types. This is adopted to the very individual patient’s risk. Nonetheless, each procedure remains associated with limitations, translating into sustained overall mortality of the underlying disease.

No conflict of interest has been declared by the author(s).