Dx Dialogues: What is the difference in outcomes with TAVR vs. SAVR?

So the outcomes for TAVR versus SAVR really depend on the patient population. [GENTLE MUSIC]

Hi. I am Kendra Grubb. I am the surgical director of the Structural Heart and Valve Center at Emory University.

I am an adult cardiac surgeon, which means that by the combination of those two titles, I do traditional open heart surgery, as well as the newer

technologies using catheters and wires in order to implant new valves in the heart without opening the breastbone.

As you can imagine, for a patient who's high risk for surgery or elderly, they're going to do better with transcatheter aortic valve

replacement and the quick recovery. For intermediate risk patients, there's not a lot of difference. And intermediate risk is defined as that 65 to 85-year-old

patient that are at risk of dying from an open heart surgery, somewhere in the 3% to 8% range.

Those patients are going to do very similar as well in the short term. For low-risk patients, we really only have about five-year data.

And for low-risk patients, these are going to be your younger patients. In the low-risk trials, these patients were, on average, 73 or 74 years old, and there was essentially,

at five years, no difference in the composite outcome of death, stroke, or heart failure rehospitalization.

Now, in the early phase, at the one-year point, in the partner study, which is a balloon expandable valve,

they compared a balloon expandable valve to surgery. They found superiority at one year,

but over time, the benefit of surgery increased such that the lines for mortality

crossed at two to three years, so there's no difference in mortality at five years.

And these patients will be followed for 10. So will those curves continue? We don't know. We need to be following these patients for five more years.

The other low-risk study of the self-expanding valve, which is called an evolut, in that study,

there was no difference in the composite of death or stroke at one year.

Heart failure rehospitalization was not included in their primary endpoint. And their curves are diverging, favoring TAVR.

So only time will tell in our young low-risk patient populations what ultimately will be best.

In terms of the individual patient, as I counsel my patients, TAVR consistently has a risk of death

in about the 1% to 2% range. For stroke, the risk of stroke for TAVR has hovered in the 2

to 2 and 1/2 percent range, which is slightly lower than for surgical aortic valve replacement. Mortality has been about the same.

The biggest difference is that there is a higher rate of pacemaker implantation for the TAVR group.

This has to do with how the valve pushes on the electrical circuitry going through the heart. One of the major circuitry centers

sits right underneath the aortic valve, and when the TAVR valve pushes on the conduction system, when

it interferes with the node, then you can create heart block and require for the patient to end up

needing a permanent pacemaker. So the rate of permanent pacemaker for TAVR is now in the 8% to 10% range.

It had been as high as 20, but that's decreased over time with better devices and better techniques. For surgical aortic valve replacement,

that rate is more in the 5% to 8% range. So slightly higher risk of pacemaker, similar rates

of mortality and rehospitalization for heart failure for both, and the biggest difference, well, it's that reovery.