Results of a heart team assessment of aortic stenosis candidates for percutaneous valve replacement in an upper-middle-income country

Abstract Objectives To analyze the results of patients with aortic stenosis (AS) who were evaluated by a heart team (HT) over a period of 10 years in a center in our city. Methods We designed a retrospective cohort study including consecutive patients with AS who were potential candidates for transcatheter aortic valve replacement (TAVI) between January 2012 and July 2021. Cases were discussed weekly by a HT consisting of at least one cardiovascular surgeon, one interventional cardiologist, one imaging specialist and one clinical cardiologist specializing in valve disease. The HT considered, among other things, the severity of AS, symptoms, surgical risk, suitability for the procedure, frailty using a 5-point scale, and access to high-cost technology. A final decision was made for all patients assessed, including TAVI, surgical aortic valve replacement (SAVR) or conservative medical treatment (CMT). The proposed treatment and the implementation of the interventions were compared. Follow-up was by personal or telephone contact. Actuarial survival analysis (Kaplan-Meier curves) included only patients who adhered to HT recommendations. Cox regression was used to identify predictors of survival. Results Of the 841 patients included in the study, 455 (53%) were assigned to TAVI (85% implanted), 213 (24%) to SAVR (86% operated) and 183 (23%) to CMT. The percentage of patients undergoing TAVI increased from 48 to 65% (p<0.05) over the last 4 years. Patients undergoing TAVI were slightly older (86±7 vs 83±7 years), with higher EUROSCORE II (6.2, 95%CI 5.7-6.6 vs 5.6, 95%CI 4.4-6.5) and frailer (1.62±1 vs 0.94±1, p<0.01) compared to SAVR. CMT patients were similar to TAVI patients, but frailer (1.74±1) and with a larger aortic valve area (0.70 cm2, 95%CI:0.5-0.8 vs. 0.65, 95%CI: 0.5-0.8). Survival at 1 year was 88% (95%CI: 84-91) for TAVI, 83% (95%CI: 76-88) for SAVR and 70% (95%CI: 60-87) for CMT. At 2 years, survival was 82% (95%CI: 77-86) for TAVI, 78% (95%CI: 70-84) for SAVR and 59% (95%CI: 48-68) for CMT (p<0.001). Significant independent predictors of actuarial mortality were CMT (HR 1.99), age (HR 1.04), left ventricular ejection fraction (HR:0.98), diabetes (HR:1.52) and renal impairment (1.58). Conclusions Ten years after the establishment of an aortic stenosis heart team in an upper-middle-income country, approximately half of patients have undergone transcatheter aortic valve replacement allocation, and this percentage has increased over time despite economic constraints. The remaining patients were equally divided between surgical and medical management. Survival was similar at two years in patients who underwent transcatheter aortic valve replacement or surgical aortic valve replacement, suggesting that the heart team made an appropriate recommendation. Conservative medical management was an independent predictor of higher mortality.interv 1=TAVI Interv 2=SAVR interv 3=CMT