Original title: Impact of wait times on the effectiveness of transcatheter aortic-valve replacement (TAVR) in severe aortic valve disease: a discrete event simulation model. Reference: Wijeysundera HC et al. Can J Cardiol. 2014; Epub ahead of print.
Once patients are accepted for percutaneous aortic valve replacement (TAVR), the higher the expected for the valve, the greater the risk of dying by peri-procedure or within a year.
In the PARTNER A study that used the Edwards Sapien balloon expandable valve a mathematical model to simulate the death risk was applied, according to the time elapsed (from 10 days to 180 days) while completing diagnostic studies to accept it as TAVR candidate and the time at which the procedure was performed. The daily risk of dying both peri-procedure or within one year post implant, increased progressively with longer waiting time, showing a difference of up to 27% between the longest and shortest waiting time for inoperable patients (10 day waiting time 1.9% risk, 60 days 10.7%, and 180 days 28.9%) and up to 20% of difference in high-risk patients (10 days 2.2% risk, 60 days 8.1% and 180 days 22.4%).
In contrast to this, waiting time and death risk were relatively stable for those who received medical treatment or surgery, respectively. In the inoperable cohort, most patients receiving TAVR (99.2%) had lower mortality than those receiving medical treatment beyond what they had to wait for the procedure. In the high-risk cohort, when the waiting time exceeded 60 days, patients receiving TAVR showed higher mortality than those receiving surgery. With longer waits for 180 days, non-inferiority between TAVR and proven surgery in PARTNER A study missed almost half of the patients.
Conclusion
Modest increases in waiting time to percutaneous aortic valve replacement have a significant impact on mortality in the inoperable cohort as well as in the high-risk cohort.
Editorial comment
The findings of this study are particularly important for those patients who might be candidates for surgery so as to TVAR, since the loss of time could tip the balance in favour of surgery.
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