Comparison of TAVR With SAVR in Younger Low Surgical Risk Patients With Severe Aortic Stenosis (NOTION-2)

Nordic Aortic Valve Intervention Trial 2 - A Randomized Multicenter Comparison of Transcatheter Versus Surgical Aortic Valve Replacement in Younger Low Surgical Risk Patients With Severe Aortic Stenosis

A randomized clinical trial investigating transcatheter (TAVR) versus surgical (SAVR) aortic valve replacement in patients 75 years of age or younger suffering from severe aortic valve stenosis.

Study hypothesis: The clinical outcome (death of any cause, stroke and rehospitalization (related to the procedure, valve or heart failure)) obtained within one year after TAVR is non-inferior to SAVR.

Study Overview

• Status: Active, not recruiting
• Conditions: Heart Diseases; Cardiovascular Diseases; Aortic Valve Stenosis; Heart Valve Diseases; Ventricular Outflow Obstruction
• Intervention / Treatment: Device: Transcatheter aortic valve replacement; Device: Surgical aortic valve replacement

Detailed Description

BACKGROUND: Acquired aortic valve stenosis (AS) is the most common heart valve disease in the Western World with a prevalence of 2-7% at the age of >65 years. If untreated, it may lead to heart failure and death. Surgical aortic valve replacement (SAVR) until recent years has been the definitive treatment for patients with severe symptomatic AS. A less invasive transcatheter aortic valve replacement (TAVR) has been developed and has been a treatment of choice mostly for elderly high risk or inoperable patients. As TAVR technology is continuously evolving and improving, it may be anticipated that it will become a valuable alternative - and even the preferred choice of treatment - for younger, low-risk patients with severe aortic valve stenosis in the near future. However, to date, there is no clinical evidence that supports this hypothesis.

AIM: The purpose of the study is to compare TAVR and SAVR with regard to the intra- and post-procedural morbidity and mortality rate, hospitalization length, functional capacity, quality of life, and valvular prosthesis function in younger, low risk patients with severe bicuspid or tricuspid AS, scheduled for aortic valve replacement.

POPULATION: Younger low risk patients with severe aortic valve stenosis, which are scheduled for aortic valve replacement using a bioprosthesis. Subjects fulfilling the inclusion criteria, not having any exclusion criteria, and consenting to the trial will be randomized 1:1 to TAVR or SAVR with 186 patients in each group.

DESIGN: The study is a randomized clinical multicenter trial. Central randomization with variable block size and stratification by gender and coronary comorbidity will be used. An independent event committee blinded to treatment allocation will adjudicate safety endpoints.

INTERVENTIONS:

TAVR: Any CE-Mark approved transcatheter aortic bioprosthesis may be used in the study, and the choice is at the discretion of the local TAVR team. The transfemoral TAVR procedure may be performed under general anaesthesia, local anaesthesia/conscious sedation, or local anesthesia. Percutaneous coronary intervention (PCI) can be performed up to 30 days prior to TAVR or as a hybrid procedure.

SAVR: The surgical SAVR technique follows standard protocol of the local department of cardio-thoracic surgery. The operation is performed under general anesthesia, which follows standard protocol of the department of anesthesiology. A commercial available surgical aortic bioprosthesis at the surgeons discretion will be implanted. Concomitant coronary artery bypass graft (CABG) surgery may be performed.

END POINTS: The primary endpoint is the composite rate of death of any cause, stroke and rehospitalization (related to the procedure, valve or heart failure) within one year after the procedure. Secondary endpoints are listed below. Follow-up will be performed after 1 and 12 months and yearly thereafter for a minimum of 10 years.

• Study Type: Interventional
• Enrollment (Actual): 376
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Lars Søndergaard, MD; DMSc; Email: Lars.Soendergaard.01@regionh.dk

Study Locations

• Denmark
  • Copenhagen, Denmark, 2100
    • Rigshospitalet, Copenhagen University Hospital
  • Århus, Denmark, 8000
    • Aarhus University Hospital
• Finland
  • Helsinki, Finland, FI00029
    • Helsinki University Central Hospital
  • Oulu, Finland, 90220
    • Oulu University Hospital
  • Turku, Finland, 20520
    • Turku University Hospital
• Iceland
  • Reykjavík, Iceland, 101
    • Landspital
• Norway
  • Bergen, Norway, 5021
    • Haukeland University Hospital
• Sweden
  • Göteborg, Sweden, 413 45
    • Sahlgrenska University Hospital
  • Stockholm, Sweden, 171 76
    • Karolinska University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 73 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 75 years or younger.
• Severe calcific AS (Valve area <1cm2 (or <0.6 cm2/m2) AND one of the two following criteria: mean gradient >40mmHg or peak jet velocity >4.0m/s, OR in presence of low flow, low gradient with reduced or normal LVEF<50%, a dobutamine stress echo should verify true severe AS rather than pseudo-AS
• Symptomatic with angina pectoris, dyspnea or exercise-induced syncope or near syncope OR asymptomatic with abnormal exercise test showing symptoms on exercise clearly related to AS or systolic LV dysfunction (LVEF <50%) not due to another cause.
• Anticipated usage of biological aortic valve prosthesis.
• Low risk for conventional surgery (STS Score <4%).
• Suitable for both SAVR and transfemoral TAVR.
• Life expectancy >1 year after the intervention.
• Informed consent to participate in the study after adequate information about the study before randomization and intervention.

Exclusion Criteria:

• Coronary artery disease, not suitable for both percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).
• Coronary angiogram with a SYNTAX-score >22.
• LVEF <25% without contractile reserve during dobutamine stress echocardiography.
• Porcelain aorta, which prevents open-heart surgery.
• Bicuspid valve with aorta ascendens diameter ≥45mm
• Severe femoral, iliac or aortic atherosclerosis, calcification, coarctation, aneurysm or tortuosity, which prevents transfemoral TAVR.
• Need for open heart surgery other than SAVR with or without CABG.
• Myocardial infarction within last 30 days
• Stroke or TIA within the last 30 days. NOTION-2, 01. February 2017, version 5 9
• Current endocarditis, intracardiac tumor, thrombus or vegetation.
• Ongoing severe infection requiring intravenous antibiotics.
• Unstable pre-procedural condition requiring intravenous inotropes or mechanical assist device (IABP, Impella) on the day of intervention.
• Kidney disease requiring dialysis or severely impaired lung function (FEV1 and/or diffusion capacity <40% of predicted).
• Allergy to heparin, iodid contrast agent, warfarin, aspirin or clopidogrel.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Transcatheter aortic valve replacement	Device: Transcatheter aortic valve replacement; Retrograde transfemoral transcatheter aortic valve replacement with any CE mark approved aortic bioprosthesis with or without concomitant percutaneous coronary intervention.; Other Names: TAVI; TAVR; Transcatheter aortic valve implantation
Active Comparator: Surgical aortic valve replacement	Device: Surgical aortic valve replacement; Conventional surgical aortic valve replacement with a bioprosthesis using normothermic cardiopulmonary bypass and cold blood cardioplegia cardiac arrest with or without concomitant coronary artery bypass graft surgery.; Other Names: SAVR

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Composite rate of all-cause mortality, stroke and rehospitalization (related to the procedure, the valve or heart failure) within one year after the procedure.	VARC-3 definitions	at one year post-procedural.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Procedure time	hours	Intraoperative
Duration of index hospitalization	days	Number of days from admission to discharge (expected an averge of 7 days)
Composite rate of all-cause mortality, stroke and rehospitalization (related to the procedure, the valve or heart failure)	VARC-3 definitions	at 1 month and yearly thereafter up to 10 years post-procedure
Composite rate of all-cause mortality, disabling stroke and rehospitalization (related to the procedure, the valve or heart failure)	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Rehospitalization both composite and individual of related to the procedure, the valve or heart failure)	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Composite rate of all-cause mortality and disabling stroke	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
All-cause mortality	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Cardiovascular mortality	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Non-cardiovascular mortality	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Stroke	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Disabling Stroke	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Non-disabling stroke	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Transient Ischemic attack	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Myocardial Infarction	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Endocarditis	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Valve Thrombosis	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Need for aortic valve re-intervention	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Bleeding (life-threatening or major)	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Vascular complication (major)	VARC-3 defintions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Acute kidney injury (stage 2 or 3)	VARC-3 defintions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Echocardiographic aortic bioprosthesis performance (degree of paravalvular leakage, valve area, mean gradient, prosthesis patient mismatch)	VARC-3 definitions	at discharge, 1 and 12 months, and yearly thereafter up to 10 years post-procedure
NYHA functional class	NYHA functional class	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Need for permanent pacemaker	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
New onset atrial fibrillation captured on ECG	VARC-3 definitions	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Left ventricle remodeling as assesed by echocardiography	Left ventricle internal diameter in diastoli	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure
Quality of life change from baseline	Kansas City Cardiomyopathy Questionnaire, scale 0 (worse) to 100 (better)	at 1 and 12 months, and yearly thereafter up to 10 years post-procedure

Collaborators and Investigators

• Sponsor: Ole De Backer
• Collaborators: Boston Scientific Corporation; Abbott; Edwards Lifesciences; Symetis SA
• Investigators: Principal Investigator: Ole De Backer, MD; PhD, Rigshospitalet, Denmark; Principal Investigator: Hans GH Thyregod, MD, PhD, Rigshospitalet, Denmark

Study record dates

Study Major Dates

• Study Start (Actual): June 30, 2016
• Primary Completion (Actual): February 1, 2024
• Study Completion (Estimated): June 1, 2029

Study Registration Dates

• First Submitted: June 29, 2016
• First Submitted That Met QC Criteria: July 3, 2016
• First Posted (Estimated): July 7, 2016

Study Record Updates

• Last Update Posted (Actual): April 9, 2024
• Last Update Submitted That Met QC Criteria: April 6, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: Randomized clinical trial; aortic valve replacement; heart valve disease; valvular bioprosthesis
• Additional Relevant MeSH Terms: Pathological Conditions, Anatomical; Aortic Valve Disease; Heart Diseases; Cardiovascular Diseases; Aortic Valve Stenosis; Constriction, Pathologic; Heart Valve Diseases; Ventricular Outflow Obstruction
• Other Study ID Numbers: H-15019580

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO