Comparison of Balloon-Expandable vs Self-Expandable Valves in Patients undergoing Transcatheter Aortic Valve Replacement: The CHOICE Randomized Clinical Trial

IMPORTANCE:

Transcatheter aortic valve
replacement (TAVR) is an effective treatment option for high-risk
patients with severe aortic stenosis. Different from surgery,
transcatheter deployment of valves requires either a balloon-expandable
or self-expandable system. A randomized comparison of these 2 systems
has not been performed.

OBJECTIVE:

To determine whether the balloon-expandable device is associated with a better success rate than the self-expandable device.

DESIGN, SETTING, AND PATIENTS:

The
CHOICE study was an investigator-initiated trial in high-risk patients
with severe aortic stenosis and an anatomy suitable for the transfemoral
TAVR procedure. One hundred twenty-one patients were randomly assigned
to receive a balloon-expandable valve (Edwards Sapien XT) and 120 were
assigned to receive a self-expandable valve (Medtronic CoreValve).
Patients were enrolled between March 2012 and December 2013 at 5 centers
in Germany.

INTERVENTIONS:

Transfemoral TAVR with a balloon-expandable or self-expandable device.

MAIN OUTCOMES AND MEASURES:

The
primary end point was device success, which is a composite end point
including successful vascular access and deployment of the device and
retrieval of the delivery system, correct position of the device,
intended performance of the heart valve without moderate or severe
regurgitation, and only 1 valve implanted in the proper anatomical
location. Secondary end points included cardiovascular mortality,
bleeding and vascular complications, postprocedural pacemaker placement,
and a combined safety end point at 30 days, including all-cause
mortality, major stroke, and other serious complications.

RESULTS:

Device
success occurred in 116 of 121 patients (95.9%) in the
balloon-expandable valve group and 93 of 120 patients (77.5%) in the
self-expandable valve group (relative risk [RR], 1.24, 95% CI,
1.12-1.37, P < .001). This was attributed to a significantly lower frequency of residual more-than-mild aortic regurgitation (4.1% vs 18.3%; RR, 0.23; 95% CI, 0.09-0.58; P < .001) and the less frequent need for implanting more than 1 valve (0.8% vs 5.8%, P = .03) in the balloon-expandable valve group. Cardiovascular mortality at 30 days was 4.1% in the balloon-expandable valve group and 4.3% in the self-expandable valve group (RR, 0.97; 95% CI, 0.29-3.25; P = .99). Bleeding and vascular complications were not significantly different, and the combined safety end point occurred in 18.2% of those in the balloon-expandable valve group and 23.1% of the self-expandable valve group (RR, 0.79; 95% CI, 0.48-1.30; P = .42). Placement of a new permanent pacemaker was less frequent in the balloon-expandable valve group (17.3% vs 37.6%, P = .001).

CONCLUSIONS AND RELEVANCE:

Among
patients with high-risk aortic stenosis undergoing TAVR, the use of a
balloon-expandable valve resulted in a greater rate of device success
than use of a self-expandable valve.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01645202.