Improving the Safety of Transcatheter Aortic Valve Replacement – Comparison of Swedish and American Approach

Abstract

Introduction: Aortic stenosis is the most common structural heart disease. After symptom onset, the prognosis is very poor – over 50% of patients die within 2 years – unless they undergo aortic valve replacement. Transcatheter aortic valve replacement (TAVR) is the minimally invasive method for valve replacement. Being a relatively new procedure, it is executed in different fashions in different institutions. Accordingly, complications and results vary a lot. Further research is needed to identify ways to reduce complications. Aim: The aim of this project was to identify the milestones in the development of TAVR protocols in different institutions and to investigate how the different protocols affect the complication rates. Methods: A total of 1153 patients were included in the study. The data was collected from national TAVR registries in Sweden and the United States – Swedeheart and TVT registry respectively. The hospitals were compared regarding the entire TAVR process – from preparation for the procedure, through procedural differences in the cath lab to complication rates afterwards. Results: There were numerous significant periprocedural differences: anaesthesia type, procedure time, contrast use, rates of pre- and postdilation. There were no significant differences in stroke rates between the institutions. The rate of pacemaker implantation post-TAVR was significantly lower in Linköping than in New York (P=0.003) 1-Year mortality was significantly lower in New York than in Gothenburg. (P=0.02) Conclusion: Overall all three centers have low mortality and morbidity rates - lower than those reported in the literature. In addition, the TAVR results are non-inferior or superior to published surgical AVR series. Excellent TAVR results can be achieved using substantially different procedural protocols and perioperative logistics. It is feasible to avoid stroke, complete heart block and risk for kidney failure. Further research is needed to combine the best procedural practises to develop the ultimate TAVR.