Transcatheter aortic valve implantation in very high-risk patients with EuroSCORE of more than 40%.

Background: Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of high-risk patients with aortic valve stenosis. Although a logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of more than 40% has been considered a contraindication for this new procedure, we routinely perform this procedure in this very high-risk patient group. We analyzed the results of TAVI patients with a EuroSCORE of over 40%.

Methods: Between April 2008 and January 2012, 514 consecutive patients underwent TAVI. In the study group (group I, EuroSCORE > 40%) of 186 patients the EuroSCORE was 63% ± 16% (range 40 to 98) and the Society of Thoracic Surgeons predicted risk of mortality score was 23% ±14% (range 4 to 90); there were 26 (14%) patients in cardiogenic shock. The mean age was 81 ± 8 (range 36 to 99) years and there were 122 women and 64 men. Group II (the control group, EuroSCORE < 40%) consisted of 328 patients. In this group the EuroSCORE was significantly lower (23% ± 9%, range 2% to 40%). The STS mortality score was 11% ± 8% (1% to 48%). In this group were 196 men and 132 women with a mean age of 78 ± 8 (range 29 to 97) years.

Results: Technically, in group I the valve was successfully implanted in 99.5% (185 of 186). In 25 (13%) patients the procedure was performed on the heart-lung machine and in 25 (13%) patients an elective percutaneous coronary intervention was performed in the same session. Postoperative echocardiography showed a low transvalvular gradient (mean 4.5% ± 2.5%, range 2 to 15) and a low rate of paravalvular regurgitation (grade 0 in 97, less than grade I in 49, less than grade II in 38 patients, and grade II in 2 patients). The overall 30-day mortality in patients with EuroSCORE of over 40% (group I), including that in patients in cardiogenic shock, was 6.5%, and in patients with EuroSCORE of over 40% (group I) and without cardiogenic shock it was 5.7%; the 1-year survival was 67% and 71%, respectively, and the 2-year survival was 54% and 56%, respectively.

Conclusions: Patients with comorbidities, as mirrored by a EuroSCORE of more than 40% should not be refused for TAVI. On the contrary, this is a supreme indication for the TAVI procedure.