In a recent study published in the Journal of the American College of Cardiology, the implementation of Transcatheter Aortic Valve Replacement (TAVR) was investigated in France.
This was an original investigation, carried out by Dr. Virginia Nguyen and her colleagues to study the number of aortic valve replacements (AVRs) performed in France, the change in trends over time and the effect that adoption of TAVR has made. TAVR has emerged as an alternative to Surgical Aortic Valve Replacement (SAVR) over time, but the nationwide data about the adoption of TAVR and the evolution of the treatment of aortic stenosis was insufficient in France.
The data in the study was based on the French administrative hospital-discharge database that included all consecutive AVRs performed between 2007 and 2015 in France. The total number of admissions for aortic stenosis between 2007 and 2015 were 131,260 and in this number, those treated with SAVR and TAVR were 109,317 (83%) and 21,943 (17%) respectively. The mean age of the population studied was 74 yr and 60% (79,123 patients) of the study population were males.
“The number of AVRs markedly increased in France between 2007 and 2015 due to the wide adoption of TAVR, which represented one-third of all AVRs in 2015.” – Virginia Nguyen et al
The rise in AVRs was mainly due to a marked increase in the number of TAVRs (p for trend = 0.0004), while the number of SAVRs remained stable (p for trend = 0.18).
The main study parameters were age, type of AVR (SAVR or TAVR) and in-hospital mortality. In-hospital mortality was defined as death occurring between the intervention and hospital discharge during the same hospital stay.
Overall, SAVR was associated with a decreased in-hospital mortality rate (3.9% vs. 5.3%; p<0.0001), a decreased rate of pacemaker implantation (4.4% vs. 14.0%; p < 0.0001), and a lower rate of stroke (1.6% vs. 2.4%; p < 0.0001), but an increased rate of acute renal failure (10.9% vs. 6.9%; p < 0.0001), than TAVR. Duration of stay was also significantly increased in the SAVR group than in the TAVR group (14.4 ` 10.7 days vs. 11.1 ` 8.6 days; p < 0.0001).
TAVR mortality rate remained higher than the mortality rate of isolated SAVR in patients <75 years of age, but became similar or slightly lesser in the 75 to 80, 80 to 84, and ≥ 85 years of age groups even if it did not reach the statistical significance (p = 0.66, p = 0.47, and p = 0.06, respectively).
The main limitations of the study were acquiring precise patient characteristics such as left ventricular ejection fraction, anatomical considerations, type of surgical prosthesis, prevalence and degree of paravalvular regurgitation. The latter is considered to be a major source of postoperative mortality and morbidity in this patient population.
The number of AVRs showed a large increase (10,892 to 18,704) in France between 2007 and 2015. This trend can be explained by the nationwide adoption of TAVR (244 to 6,722), which represented one-third of all AVRs in 2015. The patient profiles showed marked improvement as patients are now referred earlier in the course of the disease and in-hospital mortality showed a decline, especially in elderly (>75 years of age) patients.