Author + information
- Received October 20, 2017
- Revision received December 30, 2017
- Accepted January 30, 2018
- Published online April 9, 2018.
- Virginia Nguyen, MD, PhDa,b,c,
- Morgane Michel, MD, PhDc,d,e,
- Helene Eltchaninoff, MDf,
- Martine Gilard, MDg,
- Christel Dindorf, MScc,d,e,
- Bernard Iung, MDa,b,c,
- Elias Mossialos, BSc, MD, PhDh,
- Alain Cribier, MDf,
- Alec Vahanian, MDa,b,c,
- Karine Chevreul, MD, PhDc,d,e and
- David Messika-Zeitoun, MD, PhDa,b,c,∗ ()
- aDepartment of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
- bINSERM U1148, Bichat Hospital, Paris, France
- cUniversité Paris Diderot, Sorbonne Paris Cité, Paris, France
- dURC Eco Ile de France, Assistance Publique-Hôpitaux de Paris, Hôtel Dieu, Paris, France
- eINSERM, ECEVE, U1123, Paris, France
- fRouen University Hospital, INSERM U1096, FHU REMOD-VHF, Rouen, France
- gDepartment of Cardiology, Brest University Hospital, Brest, France
- hLSE Health, London School of Economics & Political Science, London, United Kingdom
- ↵∗Address for correspondence:
Dr. David Messika-Zeitoun, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada.
Background Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic valve replacement (SAVR), but unbiased data regarding evolution of the treatment of patients with aortic stenosis at the nationwide level are scarce.
Objectives This study sought to evaluate the number of aortic valve replacements (AVRs) performed in France, changes over time, and the effect of the adoption of TAVR.
Methods Based on a French administrative hospital-discharge database, the study collected all consecutive AVRs performed in France between 2007 and 2015.
Results A total of 131,251 interventions were performed: 109,317 (83%) SAVR and 21,934 (17%) TAVR. AVR linearly increased (from 10,892 to 18,704; p for trend <0.0001) mainly due to a marked increase in TAVR (from 244 to 6,722; p for trend = 0.0004), whereas SAVR remained stable (from 10,892 to 11,982; p for trend = 0.18). Parallel to a decrease in the Charlson index (p for trend <0.05), SAVR and TAVR in-hospital mortality rates significantly declined (both p for trend <0.01). The number of TAVRs significantly increased in all age categories (<75, 75 to 79, 80 to 84, and ≥85 years of age; all p for trend = 0.003), but reached or even exceeded SAVR in the 2 oldest categories. Although mortality rates declined for both isolated SAVR and TAVR, it became similar or slightly lower for TAVR than for isolated SAVR in 2015 in the 3 oldest age categories even if it did not reach statistical significance (p = 0.66, p = 0.47, and p = 0.06, respectively).
Conclusions The number of AVRs markedly increased in France between 2007 and 2015 due to the wide adoption of TAVR, which represented one-third of all AVRs in 2015. Patients’ profile improved, suggesting that patients are referred earlier, and in-hospital mortality declined in all AVR subsets. Despite a worse clinical profile, the immediate outcome of TAVR compared favorably to isolated SAVR in patients >75 years of age. The results may have major implications for clinical practice and policymakers.
Aortic stenosis (AS) is the most common valvular heart disease in Western countries and should be regarded as a major public health problem (1,2). AS prevalence increases with age and affects as many as 5% of the population after 75 years of age. AS is responsible for 300,000 surgical aortic valve replacements (SAVRs) worldwide annually, a number that is expected to double by 2050 with the aging of the population. Contrasting with the magnitude of the problem, there is no medical therapy that can stop or prevent AS progression, and consequently there is currently no alternative to aortic valve replacement (AVR) (3).
AS is mainly observed in elderly patients with commonly associated comorbidities. The Euro Heart Survey suggested that up to one-third of patients were denied surgery merely because of age (4). The last decade has seen the development of an alternative to surgery, namely transcatheter aortic valve replacement (TAVR), for patients contraindicated or considered at high risk for surgery, and this technique has profoundly changed patients’ management (5–11). However, since the first patient implanted in 2002 by Alain Cribier (12,13) and the Conformité Européenne approval in the mid-2000s in Europe, the technology has markedly improved along with the expertise of operators. Indications have been extended to lower-risk patients and data from countries such as Germany are suggesting that the number of TAVRs has caught up with the number of SAVRs (14). While recent randomized clinical trials have shown that TAVR performed at least as well (and possibly better) than SAVR for patients considered at intermediate surgical risk (15–17), uncertainties remain regarding extension of TAVR to lower-risk patients. Large unbiased registries are required to perform comparisons of both techniques in real life and to precisely and accurately analyze changes over time.
The French Programme de Médicalisation des Systèmes d’Information (PMSI) (18), a mandatory administrative database, offers the unique opportunity to assess exhaustive and comprehensive data on all consecutive AVRs performed at the nationwide level and to evaluate how the treatment of AS patients has evolved in recent years. The present study aimed to: 1) evaluate the number of AVRs performed in France, changes over time, and effect of the adoption of TAVR in clinical practice; and 2) compare SAVR and TAVR outcomes and changes occurring with time.
Study design and population
Since the July 31, 1991 law on health care reform, all health care institutions are mandated to analyze their own activity and transfer the information to the state and to the national health insurance. To do so, the PMSI database was created to collect data on patients’ diagnoses, procedures, and in-hospital outcomes (18). Each hospitalization is encoded in a standardized dataset, which includes information about the patient (age and sex), hospital, stay (date of admission, date of discharge and mode of discharge), pathologies, and procedures. Primary and secondary diagnoses are coded using the International Statistical Classification of Diseases-10th Revision (ICD-10). Procedures are coded using a French standardized classification (19).
Our study was based on 2007 to 2015 PMSI national data completed with the FRANCE (FRench Aortic National CoreValve and Edwards) study published data on TAVR performed in 2009 (20). We included all SAVRs and TAVRs performed in France both in public and in private hospitals. Our study population was identified using procedure codes for SAVR and TAVR along with the ICD-10 codes for aortic stenosis (I350, I352, I060, and I062). Patients who underwent associated cardiac surgery such as coronary bypass and mitral valve surgery were identified using their respective procedure codes. Exclusion criteria were age below 18 years and aortic regurgitation (ICD-10 codes I351 and I601, respectively). Ethical approval was not required, as all data were anonymized. The French Data Protection Authority granted access to the PMSI data.
Charlson comorbidity index
We used the Charlson Comorbidity Index (21) to assess patients’ comorbidities. Each variable (acquired immune deficiency syndrome, metastatic solid tumor, moderate or severe liver disease, malignant lymphoma, leukemia, any nonmetastatic solid tumor, diabetes with end organ damage, moderate or severe renal disease, hemiplegia, diabetes without end organ damage, mild liver disease, ulcer disease, connective tissue disease, chronic pulmonary disease, dementia, cerebrovascular disease, peripheral vascular disease, congestive heart failure, and myocardial infarction) was identified using ICD-10 codes.
In-hospital mortality was defined as death occurring between the intervention and hospital discharge during the same hospital stay. Complications were identified using their respective ICD-10 and procedures codes. Length of stay was calculated as the time duration between the admission and hospital discharge and expressed in days.
Continuous variables were expressed as mean ± SD or median (95% confidence interval) and categorical variables as number of patients (percentage). Differences in baseline characteristics and complications between groups were calculated with the use of the chi-square test for categorical variables and the Student's t-test or Wilcoxon/Kruskal-Wallis tests for continuous variables as appropriate. Trends in patients’ characteristics and outcome over time were estimated by the Mann-Kendall trend test. All tests were 2-sided and performed using SAS version 9.3 (SAS Institute, Cary, North Carolina), JMP version 9.0 (SAS Institute), or XLSTAT (Microsoft, Redmond, Washington). A p value <0.05 was considered statistically significant.
Baseline characteristics of the population
Between 2007 and 2015, 131,251 AVRs were performed in France (mean 74 ± 11 years of age; median age 76 years [95% CI: 49 to 90 years]; 79,123 [60%] men); 109,317 (83%) were SAVRs and 21,934 (17%) were TAVRs (Figure 1). SAVR was performed in isolation in 76,313 patients (70% of all SAVRs), whereas combined coronary artery bypass grafting (CABG) was performed in 28,776 (26%) and a combined mitral valve surgery in 3,693 (3.5%). A total of 535 CABG and mitral valve surgeries were performed combined with SAVR. TAVR was mainly performed through the transfemoral approach (n = 19,456 [89%]). A comparison of patients’ characteristics between SAVR and TAVR is presented in Table 1. TAVR patients were older, more frequently women, and presented with a higher Charlson score (1.10 ± 1.38 vs. 0.94 ± 1.34; p < 0.0001).
Number and type of procedures
As shown in the Central Illustration, total number of AVRs significantly and linearly increased by 72% from 2007 (10,892 replacements) to 2015 (18,704 replacements; p for trend <0.0001). The increase in AVRs was mainly due to a marked increase in the number of TAVRs (+2,557%, from 244 in 2009 to 6,722 in 2015; p for trend = 0.0004), whereas the number of SAVRs remained stable (+10%, from 10,892 in 2007 to 11,982 in 2015; p for trend = 0.18). Interestingly, both the number of isolated SAVRs (from 7,616 in 2007 to 8,270 in 2015; p for trend = 0.61) and combined SAVRs, with either CABG or mitral valve surgery (from 3,276 in 2007 to 3,712 in 2015; p for trend = 0.08) also remained stable. However, the proportion of TAVR of all AVRs significantly increased (from 2% in 2009 to 36% in 2015), whereas the proportion of isolated SAVR and combined SAVR markedly decreased (from 70% in 2007 to 44% in 2015, and from 30% in 2007 to 20% in 2015, respectively; p < 0.0001) (Figure 2).
Changes in baseline characteristics and risk profiles
Although age remained unchanged both in the SAVR and TAVR groups all along the study period, there was a marked decrease in the patients’ risk profile, as illustrated by the significant decrease of the Charlson index (Table 2). Thus, the Charlson index decreased by 35%, from 1.13 ± 1.46 in 2007 to 0.74 ± 1.14 in 2015, in the SAVR group (p for trend = 0.004), and by 31%, from 1.43 ± 1.53 to 0.98 ± 1.32 (p for trend = 0.017), in the TAVR group. In addition, the absolute number and percentage of patients who underwent a SAVR or a TAVR with a Charlson index ≥2 decreased over time (all p for trend <0.003). In the subsets of isolated and combined SAVR, Charlson index and the proportion of patients with a Charlson index ≥2 also decreased over time (all p for trend <0.006). Of note, whatever the year, the Charlson score remained higher in the TAVR group than in all SAVR groups (total, isolated, or combined) (p < 0.0001, p < 0.0001, and p < 0.05, respectively).
In-hospital mortality and complication rates over time
Crude in-hospital mortality and complication rates according to the type of intervention are reported in Table 1 and change over time in Table 2. Overall, SAVR was associated with a lower in-hospital mortality rate (3.9% vs. 5.3%; p < 0.0001), a lower rate of pacemaker implantation (4.4% vs. 14.0%; p < 0.0001), and a lower rate of stroke (1.6% vs. 2.4%; p < 0.0001), but a higher rate of acute renal failure (10.9% vs. 6.9%; p < 0.0001), than TAVR. Length of stay was also significantly longer in the SAVR group than in the TAVR group (14.4 ± 10.7 days vs. 11.1 ± 8.6 days; p < 0.0001).
In the SAVR group, although rates of combined procedure remained unchanged over time, parallel to the decrease in the Charlson score, the in-hospital mortality rate significantly declined up to 2011 and then remained relatively stable (from 5.0% in 2007 to 2.9% in 2015; p for trend <0.0001) (Table 2, Central Illustration). Stroke and acute renal failure rates remained stable (from 1.5% in 2007 to 1.4% in 2015; p for trend = 0.92; and from 10.0% in 2007 to 11.2% in 2015; p for trend = 0.36, respectively), whereas the pacemaker rate slightly increased (from 4.0% in 2007 to 5.3% in 2015; p for trend = 0.006). Similar changes in mortality and complication rates were observed in the subsets of isolated and combined SAVR (Table 2). Length of stay significantly decreased overall (from 15.3 ± 11.9 days in 2007 to 13.8 ± 10.3 days in 2015; p for trend <0.0001) and both in isolated and combined AVR subsets (both p for trend = 0.002).
In the TAVR group, in-hospital mortality markedly declined (from 12.7% in 2009 to 3.0% in 2015; p for trend = 0.003), as did the acute renal failure rate (from 11.4% in 2010 to 4.5% in 2015; p for trend = 0.02), whereas the stroke rate remained unchanged (from 3.6% in 2009 to 2.2% in 2015; p for trend = 0.77) and the pacemaker implantation rate increased (from 11.8% in 2009 to 16.0% in 2015; p for trend = 0.01). Interestingly, the mortality rate of TAVR was similar to the overall SAVR mortality rate in 2015 (3.0% vs. 2.9%; p = 0.72), but not when only isolated SAVRs were considered (3.0% vs. 2.0%; p < 0.0001) (Central Illustration). Length of stay also significantly decreased from 13.3 ± 10.1 days in 2010 to 9.9 ± 7.7 days in 2015 (p for trend = 0.003).
TAVR implementation according to age
Number of procedures
We then divided our population into 4 age categories: <75 years of age (n = 56,328, 43%), 75 to 79 years of age (n = 28,903, 22%), 80 to 84 years of age (n = 28,609, 22%), and ≥85 years of age (n = 17,157, 13%). As shown in Figure 3, the number of SAVRs increased in the youngest age category (p for trend = 0.001) but remained stable in the other 3 age categories (p for trend = 0.14, 0.36, and 0.61, respectively). In contrast, the number of TAVRs significantly increased in all age subsets (all p for trend = 0.003) and caught up and even exceeded the number of SAVRs in the 2 oldest subsets. In the 2 youngest subsets, TAVR was more marginally performed.
Overall risk profile and mortality rates
Mortality by age category is presented in Table 3 and Figure 4. The mortality rate in the TAVR group was not significantly different in all age categories (approximately 5%; p = 0.63), whereas they markedly increased with age in both isolated and combined SAVR groups (from 1.8% to 6.4% and from 4.3% to 10.8%, respectively; both p < 0.0001). Importantly, in each age category, the mortality rate was significantly different among isolated SAVR, combined SAVR, and TAVR (all p < 0.0001), but ranking changed as age increased. Thus, TAVR was associated with a higher mortality rate in the 2 youngest age categories (both p < 0.0001), but was not different between 80 and 85 years of age (p = 0.15) and was lower after 85 years of age (p = 0.03), although the Charlson index was always higher in the TAVR group.
Change in mortality rates over time
Mortality rates over time in all 4 age categories and for all 3 treatment groups (isolated SAVR, combined SAVR, and TAVR) are illustrated in Figure 5. The mortality rate in the isolated SAVR declined from 2007 to 2015, although the decrease was mainly observed in the first years (2007 to 2010; all p for trend <0.05). In contrast, the mortality rate of combined SAVR remained overall stable in all categories, except in the 80 to 85 years of age category (p for trend = 0.002). On the other hand, the TAVR mortality rate in the youngest category remained unchanged (p for trend = 0.72), but declined in the other 3 age categories (p for trend = 0.003, 0.06, and 0.003, respectively). Importantly, in 2015, the TAVR mortality rate remained higher than the mortality rate of isolated SAVR in patients <75 years of age, but became similar or slightly lower in the 75 to 80, 80 to 84, and ≥85 years of age groups even if it did not reach the statistical significance (p = 0.66, p = 0.47, and p = 0.06, respectively). It is also worth noting that the Charlson score in the isolated SAVR group was significantly lower than in the TAVR group in all 3 age categories (all p < 0.0001), and was similar above 85 years of age (p = 0.82) (Table 3).
In the present study, we report contemporary, exhaustive, nationwide data on trends in numbers, type, and outcomes of AVR in France from 2007 to 2015. Main results can be summarized as follows. First, there was a linear increase in the number of AVR performed in France (+70%; +8% per year). This increase was mainly related to the marked development and widespread diffusion of TAVR, which represented approximately one-third of all AVRs performed in 2015, whereas SAVR remained relatively stable. Second, the overall profile of patients who underwent an AVR improved over time, and we observed a parallel in-hospital mortality decrease overall and in all AVR subsets (isolated SAVR, combined SAVR, and TAVR). Third, in 2015, among patients 75 years of age or older, the in-hospital mortality rate of TAVR was similar or slightly lower than the mortality rate of isolated SAVR despite an overall worse clinical profile.
Randomized controlled trials, although critical, enroll selected patient populations and are usually performed in high-volume valve centers, and thus generalizability to real life may be questioned. Propensity matching of real-world cohorts such as the recent study based on the Society of Thoracic Surgeons National Database/American College of Cardiology TVT (Transcatheter Valve Therapy) registry are important, but are also subject to selection bias and precludes evaluation of changes over time (22). National TAVR registries have been implemented in France (8,20) as well as abroad (23–26), but only provide information of transcatheter therapies. Furthermore, participation in the FRANCE TAVI registry, which has succeeded the FRANCE 2 registry, is now only on a volunteer basis and is not anymore exhaustive, and thus it is potentially biased, as has recently been shown (27). In contrast, the PMSI database is exhaustive, consecutive, and thus includes all AVRs performed in France, as it is mandatory for all French health care institutions. The PMSI database therefore offers a unique opportunity to evaluate real-life outcomes and changes in TAVR comparatively to surgery at the nationwide level in France.
In the present study, we clearly demonstrate the dramatic increase of AVR performed in France in the last decade. Similar trends at the German nationwide level have also been reported, although for a shorter period of evaluation (28). Aortic valve stenosis is a degenerative disease whose prevalence increases with age. However, it is unlikely that the observed AVR increase was only related to the aging of the population in such a limited period of time. In addition, age-adjusted trends showed similar results (data not presented). These results raise 2 important questions: first, whether these changes can be attributed to a substitutive or complementary use of TAVR (availability and increased awareness of this novel technology); and second, whether this linear trend will continue and for how long.
As illustrated in Figure 3, the number of surgeries decreased as age increased. Thus, surgery was only marginally performed after 85 years of age and represented only 6% of all AVRs in 2007. With availability of TAVR, a dramatic increase of AVR was observed in this age category (+583%). In 2015, AVR performed after 85 years of age represented 20% of all AVRs, and the immense majority were TAVR. Thus, TAVR has addressed an unmet medical need in this elderly population and usefully complemented SAVR. As age decreased, the use of TAVR was less prominent. This is fully in line with clinical practice guidelines at that time, which restricted TAVR use to patients contraindicated for surgery or at high surgical risk. As evidence regarding TAVR efficacy has accumulated in intermediate-risk patients, a substitutive effect in the youngest age categories (especially 75 to 85 years of age) has also possibly occurred. It is worth noting that TAVR adoption seemed to have occurred earlier and faster in several countries such as Germany, possibly due to a faster shift from high- to lower-risk patients. In 2014, the number of TAVRs already exceeded the number of isolated SAVR in Germany (14).
Another striking observation of the present study was the overall decrease in the Charlson index in all AVR subsets and across all age categories. A possible interpretation of this observation is that interventions (either TAVR or SAVR) were considered at an earlier stage in the course of the disease. Elderly patients or those with comorbidities, who were often neglected and rarely considered for surgery a few years ago, are now more frequently referred to centers with surgical or transcatheter programs earlier and not so unduly conservatively managed anymore. This point also illustrates the complementary use of TAVR and SAVR. Although we could not exclude that less futile intervention may have been performed with time, it remains marginal in our opinion (29).
Parallel to the better patient profiles, outcomes improved in all AVR subsets (isolated SAVR, combined SAVR, and TAVR). In the surgical group, improvement is probably related, at least partially, to a shift from SAVR to TAVR in high-risk patients, as suggested by the decline in mortality rates that mainly occurred in the early days of TAVR (2010 to 2011). With technological improvement, experience and expertise of the operators, and better selection of patients, TAVR has reached maturity. Overall, in 2015, in-hospital mortality was only 3% compared with 2% for isolated SAVR irrespective of age and comorbidities. More specifically, when TAVR and isolated SAVR outcome were analyzed according to age categories, TAVR compared favorably to isolated SAVR in patients 75 years of age or older. On the other side, comparison of TAVR and SAVR results in patients younger than 75 years of age should take into account the fact that patients referred to TAVR in this subset are probably the sickest, with the greater comorbidity explaining the worse outcomes. Complication rates after TAVR also declined except the need for pacemaker and compared well with SAVR and length of stay was significantly shorter. The good TAVR outcomes are further reinforced by the fact that we did not individualize patients who underwent a TAVR through a transfemoral or another approach. One may argue that TAVR and SAVR populations are not comparable, but this should have played in the other direction, as the Charlson score index was consistently higher or equal in TAVR patients than in isolated SAVR patients. However, we could not exclude that patients with the worst associated conditions (either clinical or anatomical) were finally referred to surgery. Although ultimate TAVR durability remains uncertain, while waiting for the ongoing randomized trials comparing TAVR to SAVR in low-risk patients, the heart team should take into account age, anatomical, and technical aspects, as recently proposed in the latest clinical practice guidelines on valvular heart disease, when determining the best therapeutic option between TAVR and SAVR (30,31).
First, the present study was based on administrative data, with limitations inherent to such methodology. However, the scale of the database minimizes coding errors, and as coding of complications is linked to reimbursement, it is expected to be of good quality. Furthermore, age, type of AVR (SAVR or TAVR), and in-hospital mortality, the 3 major key items of the present study, are easy to collect and ascertain. Second, we were limited in our analysis to the variables present in the database, which meant that precise patient characteristics including left ventricular ejection fraction, anatomical considerations, type of surgical prosthesis, and prevalence and degree of paravalvular regurgitation (a major source of post-operative mortality and morbidity) could not be obtained. We were also not able to calculate surgical risk scores such as the EuroSCORE or the Society of Thoracic Surgeons score. However, similar declines in surgical risk scores have been reported in several TAVR and SAVR registries (23,27,28). The Charlson index was used as a surrogate, but we acknowledge that it is far from perfect, as it disregards important comorbidities or characteristics such as ejection fraction or previous cardiac surgery and is based off of coding at hospital discharge by physicians with varied expertise in this area. Third, the PMSI database is not currently linked to any death record database, and we were unfortunately not able to provide mid- or long-term survival. Finally, although the adoption timescales of TAVR may vary across countries depending on the structure of their health care system and reimbursement schemes, similar trends are expected to occur in all Western countries, as shown in Germany.
Societal and economic implications
With the aging of the population, the number of AVRs is expected to continue to grow in France as well as in all Western countries. One major issue will be at which speed this growth will occur, as it portends major implications for health system organization and budget impact. Modeling studies based on the aging of the population, and prevalence of severe AS may be helpful, but this is outside the scope of the present study. Our results could also be helpful for updating evaluation of the cost effectiveness of TAVR technology compared with SAVR (assuming a similar mid- and long-term outcome after hospital discharge) (32). Indeed, in addition to in-hospital mortality, main complication rates and length of stay were collected. Another major policy implication is to raise awareness on the major AS social and economic burden and strongly incentivize government bodies and policymakers to support research programs aimed at tackling the occurrence and progression of AS (33).
Based on an administrative database, we were able to report the changes in number, type, and outcomes of all AVRs performed in France between 2007 and 2015. We show that the number of AVRs has markedly increased due to the wide availability and adoption of TAVR, especially in elderly patients. The overall increase was associated with an improvement in patient profile, suggesting that patients are now referred earlier in the course of disease, and we observed a marked in-hospital mortality decline in all AVR subsets (isolated SAVR, combined SAVR, and TAVR). Finally, despite a worse clinical profile, the TAVR in-hospital mortality rate compared favorably with isolated SAVR in patients 75 years of age or older. Our results may have major implications for clinical practice and policymakers.
COMPETENCY IN SYSTEMS-BASED PRACTICE: In France, TAVR has transformed the management of patients with symptomatic severe AS, and maturation of the technology has been associated with a marked decline in procedural mortality and complications. Ongoing randomized trials in lower-risk patients and long-term surveillance of patients with implanted valves seem likely to make TAVR the first-line therapy for patients with symptomatic AS irrespective of age or surgical risk.
TRANSLATIONAL OUTLOOK: Data from comprehensive nationwide databases of consecutive patients undergoing AVR, despite inherent limitations, should complement ongoing randomized trials to provide insight into long-term outcomes, including the longevity of prosthetic materials and the consequences and management of their degeneration over time.
The present study was partially funded by the RHU STOP AS. Dr. Nguyen was supported by a grant from the Société Française de Cardiologie and the Fédération Française de Cardiologie. Dr. Eltchaninoff has served as a proctor for and received lecture fees from Edwards Lifesciences. Dr. Iung has received speaker fees from Edwards Lifesciences. Dr. Cribier has served as a consultant for Edwards Lifesciences. Dr. Vahanian has served as a consultant for Edwards Lifesciences, Abbott Vascular, and Mitraltech. Dr. Messika-Zeitoun has served as a consultant for Edwards Lifesciences, Mardil, and Cardiawave; and has received research grants from Edwards Lifesciences and Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- aortic stenosis
- aortic valve replacement
- coronary artery bypass grafting
- International Statistical Classification of Diseases-10th Revision
- French Programme de Médicalisation des Systèmes d’Information
- surgical aortic valve replacement
- transcatheter aortic valve replacement
- Received October 20, 2017.
- Revision received December 30, 2017.
- Accepted January 30, 2018.
- 2018 American College of Cardiology Foundation
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