Direct vs. staged TAVI in the acute management of decompensated severe aortic stenosis
Authors: Teixeira R , Neves A I , Lobo A , Almeida M , Sousa-Nunes F , Leite M , Braga P , Ponte M , Dias A , Passos-Silva M , Caeiro D , Fontes-Carvalho R 
Published: May 2024

Abstract

Funding Acknowledgements
None.

Background
Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe aortic stenosis across a spectrum of surgical risks, potentially diminishing the role of balloon aortic valvuloplasty (BAV) as a transient solution or a bridge to definitive intervention. With advancements in TAVI technology and expertise, patients even in unstable conditions are increasingly receiving direct, definitive TAVI, avoiding the risks associated with staged, multiple procedures.

Aims
The study set out to assess whether immediate TAVI is safer and more effective than BAV followed by elective aortic valve replacement (AVR) in acute severe aortic stenosis.

Methods
Conducted as a retrospective analysis at a single center, this study encompassed a cohort of consecutive patients who received either urgent or emergency BAV, as bridge to AVR, or TAVI to manage decompensated severe aortic stenosis from May 2012 to May 2023. The primary outcomes were mortality rates at both 30 days and one year following the procedures.

Results
In this cohort, 258 cases of urgent or emergent percutaneous aortic valvuloplasty were evaluated. BAV was performed in 47 patients, whereas 211 received direct TAVI. A significantly higher proportion of the BAV group (36%) was treated due to cardiogenic shock as the primary indication, compared with just 11% in the TAVI group (p&lt; 0.001). Demographic parameters and comorbid condition profiles were equivalently balanced across both groups. The median age was 81 years (interquartile range: 74-85, p= 0.40), and males constituted 56% of the patient population (p= 0.72). Most patients (65%) presented with left ventricular systolic dysfunction, and nearly half (49%) were diagnosed with obstructive coronary artery disease. The reduction in peak aortic valve gradient was significantly more pronounced in the TAVI group (-56±25 mmHg) compared to the BAV group (-27±19 mmHg, p&lt; 0.001). TAVI recipients also had a higher incidence of VARC-2 minor and major bleeding events (26% versus. 6% for BAV, p&lt;0.001), and a greater occurrence of advanced atrioventricular block necessitating temporary pacing (19% vs. 9% for BAV, p= 0.02). Thirty-day survival rates favored the TAVI group (93%) over BAV (86%). This trend persisted at the one-year mark, with survival rates of 84% for TAVI and 70% for BAV. Furthermore, the one-year hazard ratio for mortality among patients undergoing BAV was 2.01 (95% confidence interval: 1.34–3.01, p&lt; 0.001).

Conclusion
The data from this retrospective analysis indicate that for patients with decompensated severe aortic stenosis, immediate TAVI may confer a mortality benefit over BAV followed by elective procedures. Despite a higher rate of procedural complications, the direct TAVI approach was associated with better survival rates at both 30 days and one year. These outcomes suggest a potential reevaluation of treatment strategies in acute settings may be warranted.