Sunday, 3 April 2011

SO, IS THIS IT ?

TAVI matches surgery in PARTNER cohort A | theheart.org
The Partner A results are finally out. As is usual, eagerly awaited results of a trial are interpreted differently by people of different persuasions (surgical or medical). After 12 months, survival that was better with TAVI at 30 days is equivalent. This suggests to me that that the TAVI Kaplan Meier survival curve has a steeper decline. Rates of strokes and vascular incidents are higher after TAVI at 12 months. Undoubtedly freedom from significant AR will be worse after TAVI. So the only advantage that TAVI has over surgery, improved perioperative outcomes, is lost after 12 months. John Webb's assertion that strokes and vascular accidents will diminish with new iterations of the device will have to be proved. I am not convinced that this is the case. The reason for this morbidity (that incidentally leads to the later surge in mortality ) is patient not device related. I was shocked to hear that 25% of aortic stenosis patients in Germany are treated with TAVI. As far as I am concerned, at this point in time TAVI remains the evidence based alternative to best palliative care in patients who are turned down for surgery. The surgical community should continue to develop ways of identifying those elderly patients who do well after surgery and those who don't. Research looking at indices of frailty is urgently required. They should also continue to develop ways of diminishing morbidity associated with surgery in the elderly such as the increased use of minimally invasive incisions .
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