Direct TAVR superior to Balloon Aortic Valvotomy in Shock and Severe Aortic Stenosis

A new study revealed that direct Transcatheter Aortic Valve Replacement (TAVR) is a better treatment option over rescue Balloon aortic valvotomy for patients with shock and severe Aortic stenosis. The study results were published in the journal Cardiovascular Revascularization Medicine.  

The preferred procedure for Severe Aortic valve Stenosis (AS) for patients >65 years, who prefer bioprosthetic valve, have limited life expectancy, or are at high/prohibitive surgical risk for surgical aortic valve replacement is the transcatheter aortic valve replacement/Implantation (TAVR/TAVI) via transfemoral approach. Developments in this method have allowed the direct usage of this procedure as a rescue therapy for critically ill patients. As previous literature showed that emergent TAVR had better outcomes than Balloon aortic valvuloplasty (BAV) researchers conducted a study to compare the strategy of direct TAVR for cardiogenic shock complicating severe AS to urgent BAV utilizing a nationwide database of the National Inpatient Sample (NIS) between 2016 and 2020.

Using the National Inpatient Sample (NIS) Database, nearly 11,405 hospitalizations with severe AS complicated by CS were identified and patients were then stratified as per TAVR or BAV treatment that they received. The differences in baseline characteristics were identified by propensity-score matching. A comparison of the primary and secondary outcomes was carried out between 3485 hospitalizations in the direct TAVR group and 3485 matched hospitalizations in the BAV group. The primary outcome was a composite of all-cause in-hospital death, acute cerebrovascular accident (CVA), and myocardial infarction (MI). Secondary outcomes and safety outcomes were also compared between the two groups. 

Findings: 

• TAVR was associated with fewer primary outcomes events as compared to BAV, due to fewer all-cause in-hospital deaths and MI.
• TAVR was associated with higher rates of acute CVA and pacemaker implantation post-procedure. 
• Patients who undergo urgent TAVR had fewer co-morbidities as compared to patients who underwent urgent BAV. 

Thus, Direct TAVR in severe shock Aortic stenosis is a superior treatment option to rescue balloon aortic valvotomy because it reduces the risk of stroke and heart block necessitating a permanent pacemaker while improving all-cause mortality and myocardial infarction incidence during the index hospitalization.

Further reading: Llah ST, Sharif S, Ullah S, et al. TAVR vs balloon aortic valvotomy for severe aortic stenosis and cardiogenic shock: An insight from the national inpatient sample database [published online ahead of print, 2023 May 12]. Cardiovasc Revasc Med. 2023; S1553-8389(23)00181-1. doi: 10.1016/j.carrev.2023.05.006