Aortic valve replacement(AVR)
① Transcatheter aortic valve implantation (TAVI, also known as transcatheter aortic valve replacement or TAVR)
② surgical aortic valve replacement (SAVR)
수술 위험성이 중등도 또는 고위험인 증상이 있는 대동맥판 협착증 환자에서 TAVI가 SAVR보다 임상 결과가 유사하거나 우월하였습니다. 수술 위험성이 낮은 환자에서는 그 증거가 제한적이었으나 최근 2개의 연구 결과를 토대로 수술 위험성이 낮은 증상이 있는 대동맥판 협착증 환자에서도 SAVR보다 TAVI를 권고합니다. 예외로 SVAR이 선호되는 경우는 bicuspid or unicuspid aortic valve, poor transfemoral access, severe left ventricular outflow tract calcification, adverse aortic root입니다.
Low surgical risk (ie, STS-PROM <4).
Optimum criteria for choice of intervention in patients with low surgical risk are uncertain.In patients with low surgical risk with all four of the following criteria (age ≥65 years, transfemoral TAVI is feasible, aortic valve is trileaflet, and absence of high risk anatomic features [such as an adverse aortic root, low coronary ostia height, or severe left ventricular outflow tract calcification]), we recommend transfemoral TAVI (Grade 1B).For patients who lack one or more of these four criteria, SAVR is preferred.If a relative contraindication to SAVR is present (unusual in this setting), an individualized risk-benefit assessment of SAVR versus TAVI is performed.
참고 : https://blog.naver.com/sjloveu2/221843728564
Practice Changing UpDate
CARDIOVASCULAR MEDICINE (March 2019)
Transcatheter aortic valve implantation in patients with aortic stenosis and low surgical risk
● For most patients with symptomatic severe aortic stenosis who are at low surgical risk, we recommend transfemoral transcatheter aortic valve implantation (TAVI) rather than surgical aortic valve replacement (SAVR) (Grade 1B). Exceptions for which SAVR is preferred include adverse left ventricular outflow tract or aortic root anatomy.
For patients with symptomatic severe aortic stenosis and intermediate or high surgical risk, clinical outcomes with transcatheter aortic valve implantation (TAVI) are similar or superior to those with surgical aortic valve replacement (SAVR). However, evidence in patients with low surgical risk has been limited. Two randomized trials compared TAVI and SAVR in patients with severe aortic stenosis (with a trileaflet valve) and low surgical risk.
•In the Evolut Low Risk trial over 1400 patients were randomly assigned to TAVI with a self-expanding valve or SAVR. TAVI was noninferior to SAVR for the composite endpoint of death or disabling stroke at two years. Rehospitalization at one year was less frequent in the TAVI group. At 30 days, TAVI resulted in lower rates of disabling stroke, bleeding complications, and atrial fibrillation but higher rates of moderate or severe aortic regurgitation and permanent pacemaker implantation.
•In the PARTNER 3 trial, 1000 patients were randomly assigned to TAVI with a balloon-expandable valve or SAVR. The study excluded patients with poor transfemoral access or adverse left ventricular outflow tract or aortic root features. TAVI was superior to SAVR for the composite endpoint of death, disabling stroke, or rehospitalization at one year. At 30 days, TAVI resulted in lower rates of stroke and new-onset atrial fibrillation, and there were no significant differences between the treatment groups in the frequency of permanent pacemaker insertions or moderate or severe aortic regurgitation.
Based upon the results of these studies, and similar to prior recommendations for patients with higher surgical risk, we now recommend transfemoral TAVI rather than SAVR for most patients with symptomatic severe aortic stenosis with low surgical risk. However, SAVR is preferred to TAVI for patients with one or more of the following features: bicuspid or unicuspid aortic valve, poor transfemoral access, severe left ventricular outflow tract calcification, or an adverse aortic root.
1. With high surgical risk
Nearly all patients had intermediate to high surgical risk, transfemoral TAVI (but not transthoracic TAVI) was associated with lower mortality than SAVR. The meta-analysis included the following two pivotal trials in patients with high surgical risk:
① In cohort A of the PARTNER randomized trial
② The United States CoreValve High Risk randomized trial
In both trials, major vascular complications were more frequent after TAVI, and major bleeding and new-onset atrial fibrillation were more frequent after SAVR. Since data are not convincing that outcomes are different with different types of transcatheter heart valves, TAVI (with either balloon-expandable or self-expanding valve) is recommended for high-risk patients who are candidates for a transfemoral approach.
2. In intermediate-risk patients
Randomized trials in patients with severe AS with intermediate surgical risk have found similar rates of death or disabling stroke following TAVI and SAVR as summarized by the following meta-analyses:
3. In low-risk symptomatic patients
The efficacy and safety of TAVI in patients with AS with low estimated surgical risk were evaluated by the following randomized trials : Practice Changing UpDate, CARDIOVASCULAR MEDICINE (March 2019)
① In the Evolut Low Risk trial : 아래 언급 N Engl J Med. 2019;380(18):1706. Epub 2019 Mar 16.
② In the PARTNER 3 trial : 아래 언급 N Engl J Med. 2019;380(18):1695. Epub 2019 Mar 16.
REF
UpToDate 2020.03.08
N Engl J Med. 2019;380(18):1706. Epub 2019 Mar 16.
N Engl J Med. 2019;380(18):1695. Epub 2019 Mar 16.
