Clinical Factors and Outcomes When Real-World Heart Teams Overruled STS Risk Scores in TAVR Cases

Area of Science:

• Cardiovascular Medicine
• Interventional Cardiology
• Cardiac Surgery

Background:

• Historically, transcatheter aortic valve replacement (TAVR) was reserved for patients with high predicted risk of mortality (PROM).
• The Society of Thoracic Surgeons (STS) PROM >3% was a primary criterion for TAVR referral.
• Clinical rationale and outcomes for TAVR in low-risk patients were previously unclear.

Purpose of the Study:

• To investigate the reasons heart teams select TAVR over surgical AVR (SAVR) for patients with low PROM.
• To describe the clinical outcomes associated with these TAVR versus SAVR decisions in low-risk populations.

Main Methods:

• Retrospective analysis of TAVR and SAVR cases across nine hospitals from 2013 to 2017.
• Inclusion of TAVR patients with STS PROM >3% and ≤3%, and SAVR patients with STS PROM ≤3%.
• Analysis of clinical reasons for TAVR recommendation and postoperative outcomes.

Main Results:

• Frailty, hostile chest, severe lung disease, and morbid obesity were key reasons for TAVR in patients with STS PROM ≤3%.
• Postoperative outcomes were largely similar between TAVR groups (STS PROM >3% vs. ≤3%).
• Patients receiving TAVR with STS PROM ≤3% had a shorter length of stay but higher 30-day mortality compared to SAVR.

Conclusions:

• Heart teams utilize TAVR for low-risk patients based on factors beyond traditional risk scores, such as frailty and comorbidities.
• These clinical decisions appear justified by comparable postoperative results.
• While TAVR in low-risk patients showed similar outcomes to SAVR, SAVR had a lower 30-day mortality rate in this specific subgroup.