“Heart Team” decision making in elderly patients with symptomatic aortic valve stenosis who underwent AVR or TAVI – a look behind the curtain

Selected in EuroIntervention by S. Brugaletta

References

Authors

Kaier K, Gutmann A, Vach W, Sorg S, Siepe M, von Zur Mühlen C, Moser M, Blanke P, Beyersdorf F, Zehender M, Bode C, Reinöhl J

Reference

EuroIntervention. 2015 Nov 22;11(8):793-8

Published

22 November 2015

Link

Read the abstract

My Comment

Results of the prospective TAVI Calculation of Costs Trial (TCCT)

What is known 

The decision for the choice of treatment for elderly patients with symptomatic aortic valve stenosis (AS) remains controversial. According to the ESC/EACTS Guidelines, TAVI is recommended for patients considered unsuitable for conventional surgery because of severe comorbidities. In patients considered to be at high risk for conventional surgery, these comorbidities and the associated individual patient’s risk should be assessed by a “Heart Team” of cardiac surgeons and cardiologists to select the optimal treatment strategy for individual patients. Unfortunately, little evidence is available for validation and evaluation of the “Heart Team” approach. In this study the authors sought to analyse how treatment decisions are made in AS patients suitable for AVR or TAVI by a “Heart Team” approach and which patient-specific baseline parameters influence the decision-making process. 

Major findings 

  • The “Heart Team” decision-making process was analysed with respect to 124 patients of a non-randomised prospective clinical trial that included patients aged ≥75 years: 41 patients underwent AVR and 83 underwent TAVI.
  • For patients with a baseline EuroSCORE I ≥13.48%, no further cut-off points were identified and the majority of these patients underwent TAVI.
  • Among patients with a baseline EuroSCORE I <13.48%, age and left ventricular ejection fraction (LVEF) were identified as further relevant decision parameters. The decision relevance of EuroSCORE I (p=0.003), age (p=0.024) and LVEF (p=0.047) were confirmed by multivariate analysis.
  • Treatment decision (TAVI or AVR) was not a significant predictor of mortality (p=0.655).

My comment

This interesting analysis aimed to identify the factors within the Heart-team, which are taken into account in the decision making between TAVI and AVR. While the Heart-team concept, based on the Syntax trial, is well-known for coronary artery disease and easily applied by using the Syntax and the Euroscore II scores, for aortic valve disease the concept of the Heart-Team is still not well-understood, due to the fact that it is difficult to identify the variables which have to be considered in the decision-making process. In this regard, pure aortic valve scores are missing and the most important variable, which usually emerges, is age, due to the fact that TAVI procedures are usually performed in a very old population. Despite its inherent limitations because of the small sample size and its retrospective nature, the present analysis represents a first attempt to understand what really matters in the choice between the two procedures.

It would be interesting if you could share with us how the valve heart-team works in your hospital and how the choice between TAVI and AVR is made. 

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