Replacing Heart Valve Lengthened Life, But at What Cost?

Aortic stenosis treated with valve replacement may improve function but not quality of life

(RxWiki News) Aortic stenosis, a narrowing of the main heart artery, is a common problem among older adults. While valve replacement may prolong life, psychological and general health benefits may be modest.

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical valve replacement for treating aortic stenosis, the most common valvular heart disease.

New research has suggested that TAVR may improve symptoms, physical function and disease-specific measures of quality of life, but evidence that the procedure may help mental health or overall quality of life was often small and inconsistent.

"Weigh the positives and negatives of transcatheter aortic valve replacement."

Dae Hyun Kim, MD, instructor in medicine at Beth Israel Deaconess Medical Center in Boston, collaborated on a recent scientific review of 60 observational studies and two controlled trials representing a total of 11,205 patients treated with TAVR in order to evaluate patient quality of life and functional benefits of this procedure.

Up to 3 percent of adults older than 75 are affected by aortic stenosis. In these patients, the valve often narrows from calcium deposits, which restricts blood flow from the heart and increases the likelihood of heart failure. Surgical aortic valve replacement (SAVR) is the treatment of choice, according to the authors of this review. The procedure has been shown to extend life and improve quality of life.

SAVR requires cutting into the chest, separating the breastbone, connecting a heart-lung bypass machine, removing the aortic valve and sewing a new valve into place.

TAVR is a significantly less invasive procedure than this traditional type of open-heart surgery. It is often used on the elderly who are physically vulnerable or inoperable. Using an ultrasound, a doctor guides a catheter through a small opening in the skin, leading into an artery or vein and to the heart. Instead of removing the old, damaged valve, a doctor wedges a replacement valve into position, taking the place of the original valve.

TAVR is all done via catheter, so major surgery is avoided and recovery is generally much faster.

In their review of all the studies, Dr. Kim and team noted an overall trend that TAVR improved symptoms, physical function and disease-specific measures of quality of life. The evaluation of these measures was determined from questionnaires that patients completed on disease-specific topics such as cardiomyopathy (diseases of the heart muscle) and heart failure.

The stage of heart failure according to New York Heart Association (NYHA) assessment showed an overall drop of -0.8 to -2.1 classes among the TAVR patients at 6 -11 months after the procedure and at 12-23 months. Classes range from "mild" (1) to “severe” (4).

The researchers also reviewed patient answers from the Short Form-12/36 Health Survey, a widely used generic health status instrument used to assess health-related quality of life, especially among cardiac patients. The researchers noted a “clinically important” physical component score improvement ranging from 4.9 points to 26.9 points over 12 months.

The change in the mental health component score was smaller, however, ranging from 1.0 to 8.9 points.

"After review, I believe that this study adds very little to the understanding of patients treated with TAVR," said Robert Stoler, MD, Director of the Cardiac Catheterization Lab at Baylor Heart and Vascular Hospital and Co-Director of the Division of Cardiology. "I do not believe it will have significant impact on how we treat these patients."

Dr. Kim told dailyRx News, “In our review, the improvement in mental domain of the quality of life score was often modest or smaller than clinically meaningful difference.  We need more research on this.”

The authors wrote that the “benefits in psychological dimension and general health measures were often small and inconsistent. This is valuable information for older patients with symptomatic severe aortic stenosis whose goal may be to improve the quality of life and maintain functional independence rather than prolong the remaining life expectancy.”

The decision to have TAVR can be challenging in some patients, according to Dr. Kim.

“The patient, his or her family member, the patient’s primary care physician (who is familiar with patient’s health problems), and specialists (cardiologist and cardiac surgeon) should consider the risk and benefit of the procedure for the individual patient against the patient’s values and preference,” said Dr. Kim. “Eventually, more research is needed to identify best candidates for this procedure.”

This research was published February 18 in the Annals of Internal Medicine. The research was supported by the Health Resources and Services Administration and Health Resources in Action.

Review Date: 
February 17, 2014