TAVR vs AVR

[ElectLive]

Here's another interesting article that touches on a lot of these issues (cost, risk, etc) written by the well known Dr. Lars Svennson of the Cleveland Clinic: http://www.ccjm.org/content/75/11/802.full

He labels TAVR as a "disruptive" technology...please read his words, but basically a quickly adopted innovation that challenges well established protocol and medical reasoning. One thing he points out that's a bit lost in all of the risk/benefit analysis of current surgical candidate patients is that many patients are now being referred for surgical evaluation for the first time, that wouldn't have been before. Not all are undergoing TAVR, in fact just as many end up with either standard open heart or valvuloplasty, but it's still an important point I think that prior to TAVR many of these "new" patients may have simply been told by a cardiologist "I'm sorry, there's nothing we can do". So now, there's not only new hope, but hope for an expanding patient group as well.

Another interesting point made in that article is that not all pre-surgery risk analysis methods (algorithms and scores) are created equal. In an analysis of around 5,000 PARTNER patients at Cleveland Clinic, the EuroScore method was proven fairly unreliable: observed mortality of 11% versus expected mortality of 26%. In other words, according to EuroScore, the patients were forecast to be much higher risk than they actually were. Of course, this makes me wonder if there's a surgeon in Europe right now writing an article about a study indicating how the Society for Thoracic Surgery (US) algorithm is equally flawed!

As I mentioned, the cost component comes up in the article as well, and let me just paste that directly here:

"While most disruptive technologies are cheaper than the technologies they displace, this may not be the case with percutaneous valve insertion: a standard aortic heart valve costs $2,500 to $6,000, whereas percutaneously delivered valves cost $30,000. The hospital stay may turn out to be a little shorter, which may help control the overall cost. But while the hospital stay after percutaneous insertion may be shorter than for surgical valve replacement (3–5 days vs 5–7 days), percutaneous valve insertion is currently labor-intensive and requires a team of 25 to 30 people, compared with five or six for open repair."

Taking a few steps back, though, I wonder what was written about the first open heart aortic valve replacements half a century ago. Probably a lot of the same stuff, huh? Amazing breakthrough...but high risk, high cost, clinically intensive, etc. Sure, the window of evolution will be different for TAVR, but so long as the same general pathway of development occurs, more and more good news and progress seems a perfectly reasonable expectation, as evidenced by the opinions of many surgeons today. The first open heart aortic valve replacements involved a 25% - 50% mortality risk, yet today the best of the best quote 0.25%. So, 1 in 2 or 1 in 4 versus 1 in 400. Now, that's improvement.

Now, we do already have open heart replacement, of course, it's not like TAVR is the only available option, but for many patients, it actually is. So, for now at least, risk/benefit analysis belongs more to those patients than most of us. TAVR isn't perfect now, nor will it be in the future either, but let's just hope it shows a similar pathway of significant improvement over time...safer, cheaper, easier.

Sure, I understand both sides of the TAVR analysis/argument today, but just wonder instead what will be written about TAVR in 10 years, or 20 years, etc. Who knows, maybe someday there will be a TAVR.org community full of "veterans" assuring "newbies" that is safe and easy, just like we all do here today...

 

[Lynlw]

Thanks EL, Thats interesting but since it was published in 08 shortly after the PARTNER trials started, my guess would be some of the info is already outdated, even tho its only been 4 years, its been a busy 4 years as far as percutaneous valve replacement improvements
Im sure alot is still the same, but Im not sure the teams needed are so large anymore, average length of stay etc.

It funny you mention the diference in risk scores, I was just reading an article on that a few weeks ago, that for valve patients the sTS was much closer to the outcomes than euro
but I believe the approx 5000 patints at CCF were OHS patients not PARTNER who had so much better outcomes

An algorithm for predicting operative outcomes, the Society for Thoracic Surgery equation score, is a reliable way to calculate the risk of death in patients in need of aortic valve replacement. Another method, the EuroScore, has been shown to be less predictive: in an audit of data for the multicenter Placement of Aortic Transcatheter Valves (PARTNER) trial currently under way to analyze results with these procedures, in 4,892 patients undergoing open surgical repair at Cleveland Clinic and considered at high risk (EuroScore > 10), the calculated expected risk of death was 26%, but the observed death rate was 10.9%—only 42% of the expected rate.
In my personal audit of the last 594 patients who underwent open surgical aortic valve replacement and were considered to be at high risk, the expected risk of death (as calculated by the EuroScore) was 27%, but the observed risk was considerably lower at 7%—only 26% of the predicted rate."
(again this article is from 08 so the stats would be from OHS a few years before that)


I meant to add, I think one of the reasons the Euroscore isnt as accurate for valve surgeries especially compred to the STS is they update the STS pretty often as surgical stats improve
and the Euroscore, pretty much is the same since it was started in the 90s ven tho things have improved quite a bit since then

 

[ElectLive]

Very true, Lyn, thanks. I have seen some other more recent articles describing team size anywhere from 15 to 20, with suggestions of slightly lower. You know, it's funny, but based on all the various doctors listed on my insurance claims, I find it hard to believe my open heart procedure only involved 5 or 6! But anyway, certainly things are already improving in a few years time and continue to do so. The procedure in many ways has helped drive the design of the new hybird OR for example.

Right also about the 5,000 patients...I knew they were open heart (but don't think I was clear on that either) but did misread the fact that it was actually data for PARTNER not data of PARTNER since certainly not that many patients were even part of PARTNER, much less the surgical only arm, at CC. I last read that article a few months ago and probably should have paid a little more attention to it today before finally citing it! Anyway, thanks again for clarifying.