Evolving paradigms for transcatheter aortic valve replacement simplification: a single, high-volume center experience

Transcatheter aortic valve replacement (TAVR) is a well-established technique for the treatment of severe aortic stenosis (AS), with expanding indications towards younger patients at lower surgical risk. Currently, a tendency of simplification and streamlining of the TAVR procedure is gaining an increasing importance for the management of these patients. Patients undergoing TAVR in our Institution from 2015 to the end of 2020 have been enrolled in a prospective database. The patients were divided in three time tertiles according to the date of intervention (2015-2016, 2017-2018, and 2019-2020). Data on pre-procedural planning –with a particular focus on coronary computed tomography angiography (CCTA) for the evaluation of the coronary arteries prior to intervention with invasive coronary angiography (ICA) only in patients with positive/non-diagnostic scans, intra-procedural management, and outcomes were compared between the three time tertiles. Outcomes were defined according to the recently released Valve Academic Research Consortium-3 criteria. A total of 771 consecutive patients were enrolled. Patients in the 2015-2016 cohort were at higher surgical risk with more comorbidities compared to the other ones. We observed a constant reduction trend as regards the use of local vs. general anesthesia, fully percutaneous approach vs. surgical access, left radial artery vs. contralateral femoral artery as the secondary access, and stimulation via the stiff guidewire vs. right ventricular pacing. No significant differences were found as regards the rates of permanent pacemaker implantation and vascular complications, whereas peri-procedural strokes and major cardiac structural complications decreased significantly. Overall, about 60% of the total study population underwent CCTA instead of coronary angiography. No significant ischemic events occurred in the patients that underwent CCTA instead of coronary angiography. A CCTA-based approach allowed obtaining a significant reduction of healthcare-related costs. We observed a significant reduction in the length of stay across the three time tertiles, and a significant increase of technical success. No significant differences were found as regards the 30-days outcomes (device success and early safety). We found a statistically significant difference between the three cohorts, with one-year survival rates of 84.8%, 84.6%, and 91.8% for the 2015-2016, 2017-2018, and 2019-2020, respectively (P= 0.012). A simplified TAVR approach was associated to better one-year survival, whereas low baseline functional capacity, known CAD, renal impairment, and peri-procedural transfusions were related to worse outcomes. All patients experienced marked symptoms improvement and excellent prosthesis performance at follow-up. Our study showed a constant tendency to procedure streamlining, to a reduction in overall hospital length of stay, and to improved immediate procedural success and one-year outcomes. A strategy based on CCTA prior to TAVR allows sparing almost half of the ICA usually performed prior to TAVR, without any evident adverse event and with a consistent reduction of health-related costs.