Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Cardiac Surgery in the Randomized PARTNER 2A Trial

JACC Cardiovasc Interv. 2018 Nov 12;11(21):2207-2216. doi: 10.1016/j.jcin.2018.08.006. Epub 2018 Aug 28.

Abstract

Objectives: The aim of this study was to further evaluate clinical outcomes in patients with and without PCS.

Background: Prior cardiac surgery (PCS) is associated with increased surgical risk and post-operative complications following surgical aortic valve replacement (SAVR), but whether this risk is similar in transcatheter aortic valve replacement (TAVR) is unclear.

Methods: In the PARTNER 2A (Placement of Aortic Transcatheter Valve) trial, 2,032 patients with severe aortic stenosis at intermediate surgical risk were randomized to TAVR with the SAPIEN XT valve or SAVR. Adverse clinical outcomes at 30 days and 2 years were compared using Kaplan-Meier event rates and multivariate Cox proportional hazards regression models. The primary endpoint of the PARTNER 2 trial was all-cause death and disabling stroke.

Results: Five hundred nine patients (25.1%) had PCS, mostly (98.2%) coronary artery bypass grafting. There were no significant differences between TAVR and SAVR in patients with or without PCS in the rates of the primary endpoint at 30 days or 2 years. Nevertheless, an interaction was observed between PCS and treatment arm; whereas no-PCS patients treated with TAVR had higher rates of 30-day major vascular complications than patients treated with SAVR (adjusted hazard ratio: 2.66; 95% confidence interval: 1.68 to 4.22), the opposite was true for patients with PCS (adjusted hazard ratio: 0.27; 95% confidence interval: 0.11 to 0.66) (pinteraction <0.0001). A similar interaction was observed for life-threatening or disabling bleeding.

Conclusions: In the PARTNER 2A trial of intermediate-risk patients with severe aortic stenosis undergoing SAVR versus TAVR, the relative risk for 2-year adverse clinical outcomes was similar between TAVR and SAVR in patients with or without PCS.

Keywords: aortic stenosis; surgical aortic valve replacement; transcatheter aortic valve replacement; transcatheter heart valve.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve / diagnostic imaging
  • Aortic Valve / surgery*
  • Aortic Valve Stenosis / diagnostic imaging
  • Aortic Valve Stenosis / mortality
  • Aortic Valve Stenosis / surgery*
  • Canada
  • Cause of Death
  • Coronary Artery Bypass* / adverse effects
  • Coronary Artery Bypass* / mortality
  • Female
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Humans
  • Male
  • Postoperative Hemorrhage / etiology
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Stroke / etiology
  • Time Factors
  • Transcatheter Aortic Valve Replacement* / adverse effects
  • Treatment Outcome
  • United States