Interventions for valvular disease and heart failure

Transcatheter versus surgical aortic valve replacement in patients with morbid obesity: a multicentre propensity score-matched analysis

EuroIntervention 2022;18:e417-e427. DOI: 10.4244/EIJ-D-21-00891

Angela McInerney
Angela McInerney1, MD; Josep Rodés-Cabau2, MD, PhD; Gabriela Veiga3, MD; Diego López-Otero4, MD; Erika Muñoz-García5, MD; Francisco Campelo-Parada6, MD; Juan F. Oteo7, MD; Manuel Carnero1, MD, PhD; José D. Tafur Soto8, MD; Ignacio J. Amat-Santos9, MD, PhD; Alejandro Travieso1, MD; Siamak Mohammadi2, MD; Marco Barbanti, MD; Asim N. Cheema10, MD; Stefan Toggweiler11, MD; Francesco Saia12, MD; Maciej Dabrowski13, MD, PhD; Vicenç Serra14, MD; Fernando Alfonso15, MD, PhD; Henrique B. Ribeiro16, MD; Ander Regueiro17, MD; Alberto Alperi2, MD; Aritz Gil Ongay3, MD; Jose M. Martinez-Cereijo4, MD; Antonio Muñoz-García5, MD; Anthony Matta6, MD; Carlos Arellano Serrano7, MD; Alejandro Barrero9, MD; Gabriela Tirado-Conte1, MD; Nieves Gonzalo1, MD, PhD; Xoan C. Sanmartin4, MD; Jose M. de la Torre Hernandez3, MD, PhD; Dimitri Kalavrouziotis2, MD; Luis Maroto1, MD; Alberto Forteza-Gil7, MD; Javier Cobiella1, MD, PhD; Javier Escaned1, MD, PhD; Luis Nombela-Franco1, MD, PhD
1. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain; 2. Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; 3. Hospital Universitario Marques de Valdecilla, IDIVAL, Santander, Spain; 4. Hospital Clínico Universitario de Santiago, CIBERCV, Santiago, Spain; 5. CIBERCV Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, Spain; 6. Cardiology Department, Rangueil University Hospital, Toulouse, France; 7. Department of Cardiology and Cardiac Surgery, Hospital Universitario Puerta de Hierro, Majadahonda, Spain; 8. The Ochsner Clinical School, Ochsner Medical Center, New Orleans, LA, USA; 9. CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain; 10. Division of Cardiology, St. Michael’s Hospital, Toronto University, Toronto, Ontario, Canada; 11. Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland; 12. Cardiology Unit, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Bologna, Italy; 13. Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland; 14. Hospital General Universitari Vall d’Hebrón, Barcelona, Spain; 15. Department of Cardiology, Hospital Universitario La Princesa, IIS-IP, CIBER-CV, Madrid, Spain; 16. Heart Institute (InCor), Sao Paulo, Brazil; 17. Cardiology Department, Cardiovascular Institute, Hospital Clínic, Universidad de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain

Background: Morbidly obese (MO) patients are increasingly undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). However, the best therapeutic strategy for these patients remains a matter for debate.

Aims: Our aim was to compare the periprocedural and mid-term outcomes in MO patients undergoing TAVR versus SAVR.

Methods: A multicentre retrospective study including consecutive MO patients (body mass index ≥40 kg/m2, or ≥35 kg/m2 with obesity-related comorbidities) from 18 centres undergoing either TAVR (n=860) or biological SAVR (n=696) for severe AS was performed. Propensity score matching resulted in 362 pairs.

Results: After matching, periprocedural complications, including blood transfusion (14.1% versus 48.1%; p<0.001), stage 2-3 acute kidney injury (3.99% versus 10.1%; p=0.002), hospital-acquired pneumonia (1.7% versus 5.8%; p=0.005) and access site infection (1.5% versus 5.5%; p=0.013), were more common in the SAVR group, as was moderate to severe patient-prosthesis mismatch (PPM; 9.9% versus 39.4%; p<0.001). TAVR patients more frequently required permanent pacemaker implantation (14.4% versus 5.6%; p<0.001) and had higher rates of ≥moderate residual aortic regurgitation (3.3% versus 0%; p=0.001). SAVR was an independent predictor of moderate to severe PPM (hazard ratio [HR] 1.80, 95% confidence interval [CI]: 1.25-2.59; p=0.002), while TAVR was not. In-hospital mortality was not different between groups (3.9% for TAVR versus 6.1% for SAVR; p=0.171). Two-year outcomes (including all-cause and cardiovascular mortality, and readmissions) were similar in both groups (log-rank p>0.05 for all comparisons). Predictors of all-cause 2-year mortality differed between the groups; moderate to severe PPM was a predictor following SAVR (HR 1.78, 95% CI: 1.10-2.88; p=0.018) but not following TAVR (p=0.737).

Conclusions: SAVR and TAVR offer similar mid-term outcomes in MO patients with severe AS, however, TAVR offers some advantages in terms of periprocedural morbidity.

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aortic stenosismorbid obesitySAVRtavr
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