Incidence, Causes, and Predictors of Early (≤30 Days) and Late Unplanned Hospital Readmissions After Transcatheter Aortic Valve Replacement

Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS)

The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD.

Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.

Impact of Loop Diuretic Use on Outcomes Following Transcatheter Aortic Valve Implantation

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.

Prognostic Implications of Baseline B-type Natriuretic Peptide in Patients Undergoing Transcatheter Aortic Valve Implantation

B-type natriuretic peptide (BNP) levels have been shown to predict outcomes in surgical aortic valve replacement patients. BNP levels have not been well studied in patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study is to define the utility of baseline BNP levels in predicting short-term outcomes after TAVI. In this retrospective, observational, study from 2012 to 2019, we reviewed data on 1297 low-risk, intermediate-risk and high-risk patients who underwent TAVI. Patients were dichotomized into those with baseline BNP levels above or below 500 pg/ml. Our primary outcome was a composite of inpatient stroke and death. Our secondary outcome was a composite of 30-day stroke, death and readmission. There were 975 patients with a baseline BNP level of <500 pg/ml and of those, 2% had our primary composite outcome and 13% of patients had our secondary composite outcome. There were 322 patients with a baseline BNP level of ≥500 pg/ml and of those, 6% had our primary composite outcome and 19% of patients had our secondary composite outcome. Those with a baseline BNP level ≥500 pg/ml were 3.47 times more likely (confidence of interval [CI] 1.727, 6.993, p = 0.0005) to have our primary composite outcome and were 1.72 times more likely (CI 1.186, 2.506, p = 0.0043) to have our secondary composite outcome. In conclusion, after adjustments for discrepant baseline characteristics, baseline BNP levels were independently predictive of a composite of inpatient stroke or death and a composite of 30-day stroke, death or readmission after TAVI. Those low, intermediate and high-risk patients whose baseline BNP is ≥500 pg/ml may ultimately require closer post-TAVI monitoring.

Transcatheter aortic valve implantation-related futility: prevalence, predictors, and clinical risk model

Futility denotes failure to achieve the projected outcome. We investigated the prevalence, predictors, and clinical risk model of transcatheter aortic valve implantation (TAVI)-related futility. We included 464 consecutive patients undergoing TAVI from 2010 to 2017. Futility was defined as death and/or hospitalization for heart failure (HFH) within 1 year after TAVI. Of 464 patients (mean age: 84.4 years), 69% were females (EuroSCOREII: 6.3%; Society of Thoracic Surgeons [STS] score: 6.9%). Forty-six patients (9.9%) experienced TAVI-related futility, and 36 of 46 patients (69.6%) died within 1 year due to cardiac (37.5%) and non-cardiac (62.5%) causes. Previous HFH (hazard ratio [HR], 2.20; 95% confidence interval [CI]: 1.13-4.35, p = 0.020), chronic obstructive pulmonary disease (COPD) (HR, 3.39; 95% CI: 1.12-8.42, p = 0.033), and moderate/severe mitral or tricuspid regurgitation (HR, 2.98; 95% CI: 1.32-6.27, p = 0.010) were independent predictors of futility. With 1 point assigned to each predictor (total 0 point, futility low-risk; total 1 point, futility intermediate-risk; total 2-3 points, futility high-risk), the futility risk model clearly stratified individual futility risk into three groups (the freedom from futility at 1 year: 96.2%, 82.1%, and 67.9% each). Our futility risk model presented better discrimination than EuroSCOREII, and STS score (c-statistic: 0.73 vs. 0.68 vs. 0.67). Medical futility was recognized in 9.9% of patients undergoing TAVI. Previous HFH, COPD, and concomitant atrioventricular regurgitation were associated with futility. The risk model derived from three predictors showed good performance in predicting futility risk.

Outcomes of Patients With Severe Symptomatic Aortic Valve Stenosis After Chest Radiation: Transcatheter Versus Surgical Aortic Valve Replacement

Background Patients with symptomatic severe aortic stenosis and a history of chest radiation therapy represent a complex and challenging cohort. It is unknown how transcatheter aortic valve replacement ( TAVR ) compares with surgical aortic valve replacement in this group of patients, which was the objective of this study. Methods and Results We retrospectively reviewed all patients with severe aortic stenosis who underwent either TAVR or surgical aortic valve replacement at our institution with a history of mediastinal radiation (n=55 per group). End points were echocardiographic and clinical outcomes in-hospital, at 30 days, and at 1 year. Inverse propensity weighting analysis was used to account for intergroup baseline differences. TAVR patients had a higher STS score than surgical aortic valve replacement patients (5.1% [3.2, 7.7] versus 1.6% [0.8, 2.6], P<0.001) and more often ( P<0.01 for all) a history of atrial fibrillation (45.5% versus 12.7%), chronic lung disease (47.3% versus 7.3%), peripheral arterial disease (38.2% versus 7.3%), heart failure (58.2% versus 18.2%), and pacemaker therapy (23.6% versus 1.8%). Postoperative atrial fibrillation was less frequent (1.8% versus 27.3%; P<0.001) and hospital stay was shorter in TAVR patients (4.0 [2.0, 5.0] versus 6.0 [5.0, 8.0] days; P<0.001). The ratio of observed-to-expected 30-day mortality was lower after TAVR as was 30-day mortality in inverse propensity weighting-adjusted Kaplan-Meier analyses. Conclusions In patients with severe aortic stenosis and a history of chest radiation therapy, TAVR performs better than predicted along with less adjusted 30-day all-cause mortality, postoperative atrial fibrillation, and shorter hospitalization compared with surgical aortic valve replacement. These data support further studies on the preferred role of TAVR in this unique patient population.

Impact of Frailty on Mortality, Readmissions, and Resource Utilization After TAVI

With aging population and preponderance of severe aortic stenosis occurring in elderly patients, the number of transcatheter aortic valve implantations (TAVI) performed in the elderly are growing. Frailty is common in the elderly and is known to be associated with worse outcomes. We aimed to evaluate the impact of frailty on hospital readmissions rates after TAVI. We used the 2016 Nationwide Readmission Database and categorized patients who underwent TAVI low, intermediate, and high frailty status. The primary outcome was 6-months readmission rates across the 3 frailty categories. Secondary outcomes included causes of readmissions, in-hospital mortality and cost of care. STATA 16.0 was used for survey-specific statistical tests. Of 20,504 patients who underwent TAVI, 58.9% were low-, 39.6% were intermediate-, and 1.5% were in the high-frailty group. Overall in-hospital mortality was 1.9% (n = 396), and was 0.6%, 3.3%, and 16.8% (p <0.01) with increasing frailty. Of the 20,108 patients who survived to discharge, 6,427 (32%) patients were readmitted within 6-months after TAVI. Readmission rates increased across the categories from 27.9% in low, 37.6% in intermediate and 51.1% in high frailty group (p <0.01). While cardiac causes (mostly heart failure) were the predominant readmission etiologies across frailty categories (low: 51.2%, intermediate: 34.1%, high: 27.2%), rates of infectious and injury-related readmissions increased (low: 11%, intermediate: 30%, high: 45%). Mortality during readmissions also worsened from 0.8%, 5.3%, and 8.5% (p <0.01). Over 40% of patients undergoing TAVI were of intermediate-high frailty. In conclusion, an increasing frailty was associated with significantly worse postprocedure mortality, readmissions, and related mortality.

Determinants and Impact of Heart Failure Readmission Following Transcatheter Aortic Valve Replacement

Background:

Heart failure (HF) readmission is common post–transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death.

Methods:

Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death.

Results:

Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99–1.85]). However, late (HR, 1.90 [95% CI, 1.30–2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17–3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48–0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37–0.98]) of the optimal daily dose.

Conclusions:

HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.

Evaluation of the incidence, timing, and potential recovery rates of complete atrioventricular block after transcatheter aortic valve implantation: a Japanese multicenter registry study

Data on the accurate onset date and serial changes of the complete atrioventricular block (CAVB) after transcatheter aortic valve implantation (TAVI) are limited. This study aimed to assess the incidence, timing, and potential recovery of CAVB following TAVI. Total 696 patients who underwent TAVI were enrolled. Acute CAVB was evaluated within 24 h; delayed CAVB was evaluated 24 h after TAVI. Recovered CAVB was defined as ventricular pacing < 1% during the follow-up or transit block without the need for permanent pacemaker implantation (PMI). The other patients with CAVB were categorized as continued CAVB. Clinical differences between the recovered and continued CAVB groups were evaluated, and the predictive factors of continued CAVB were assessed. The incidence rates of CAVB, acute CAVB, and delayed CAVB were 6.9% (48/696), 4.6% (32/696), and 2.3% (16/696), respectively. Overall, 47.9% (23/48) of patients had recovered CAVB, which was more prevalent in the acute CAVB group than in the delayed CAVB group [59.4% (19/32) vs. 25.0% (4/16), p = 0.025]. CAVB recovery occurred within 24 h (61.0%, 14/23) and after 24 h (39.0%, 9/23). Before CAVB recovery, 21.7% (5/23) of patients had already undergone PMI. A pre-existing complete right bundle branch block (CRBBB) was the only independent predictive factor of continued CAVB (odds ratio 4.51, 95% confidence interval 1.03-19.6, p = 0.045). In conclusion, a pre-existing CRBBB and the timing and prolonged duration of CAVB may be used in risk stratification to determine the appropriateness of early discharge, optimal PMI date, and PMI indication.

Left Ventricular Hypertrophy Does Not Affect 1-Year Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to evaluate the association between pre-procedural left ventricular hypertrophy (LVH) patterns and clinical outcomes after transcatheter aortic valve replacement (TAVR).

BACKGROUND

The association between pre-procedural LVH pattern and severity and clinical outcomes after TAVR is uncertain.

METHODS

Patients (n = 31,199) across 422 sites who underwent TAVR from November 2011 through June 2016 as part of the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapies) Registry linked with the Centers for Medicare and Medicaid Services database were evaluated by varying LVH patterns, according to sex-specific cutoffs for left ventricular mass index and relative wall thickness. The association between LVH pattern (concentric remodeling, concentric LVH, and eccentric LVH) and outcomes (rates of mortality, myocardial infarction [MI], stroke, new dialysis requirement) at 1-year follow-up were evaluated using multivariate hazard models.

RESULTS

There were no significant associations between concentric remodeling (death: adjusted hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 0.93 to 1.15; MI: HR: 1.05; 95% CI: 0.76 to 1.46; stroke: HR: 1.11; 95% CI: 0.89 to 1.39; new dialysis: HR: 0.86; 95% CI: 0.64 to 1.15), concentric LVH (death: HR: 1.04; 95% CI: 0.95 to 1.15; MI: HR: 1.12; 95% CI: 0.82 to 1.52; stroke: HR: 1.14; 95% CI: 0.92 to 1.40; new dialysis: HR: 1.17; 95% CI: 0.90 to 1.52), or eccentric LVH (death: HR: 0.98; 95% CI: 0.87 to 1.10; MI: HR: 1.07; 95% CI: 0.71 to 1.63; stroke: HR: 1.01; 95% CI: 0.78 to 1.32; new dialysis: HR: 1.25; 95% CI: 0.92 to 1.70) and outcomes at 1 year compared with patients without LVH.

CONCLUSIONS

In a contemporary cohort of patients who underwent TAVR, pre-procedural LVH according to left ventricular mass index and relative wall thickness was not associated with adverse outcomes at 1-year follow-up. TAVR is likely to benefit patients with severe aortic stenosis regardless of the presence of LVH.

Prognostic impact of myocardial contraction fraction in patients undergoing transcatheter aortic valve replacement for aortic stenosis

BACKGROUND

Myocardial contraction fraction (MCF), a volumetric measurement of myocardial shortening, may help to improve risk stratification in patients with severe aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR) especially in those with preserved left ventricular ejection fraction (LVEF). We investigated the association between MCF and 1-year all-cause mortality in patients with severe AS who underwent TAVR.

METHODS

MCF was calculated as the ratio of stroke volume (SV) to myocardial volume. Patients referred for TAVR from 2011 to 2015 were eligible for inclusion and were divided into two groups according to the estimated MCF (MCF ≤30% vs. MCF >30%). The primary endpoint was 1-year all-cause mortality. A Cox regression analysis was performed for independent risk factors of mortality. Receiver operating curve (ROC) was performed for assessing the best cut-off point of MCF for predicting the primary outcome [area under the curve (AUC) 0.60; 95% confidence interval (CI): 0.453-0.725]. Baseline patient and echo characteristics were included for multivariate analysis.

RESULTS

Of 126 patients (mean age 82±5 years, 45.2% male), 44.4% showed MCF ≤30%. Patient with reduced MCF showed higher body mass index (28.1±5.8 vs. 26.0±4.5 kg/m2, P=0.031), higher surgical EuroScore II (6.2±4.5 vs. 4.7±3.2, P=0.032), lower LVEF (54.2%±11.9% vs. 58.5%±10.8%, P=0.042) and more severe AS (indexed aortic valve area 0.40±0.09 vs. 0.45±0.10 cm2/m2, P=0.030). The median follow-up was of 14 [3.5-33] months, and 16% of patients died. Patients with MCF ≤30% showed significantly increased all-cause mortality (Log-rank P=0.002). In a multivariate model adjusting for clinical and echo variables, MCF ≤30% was independently associated with increased risk for all-cause 1-year mortality [hazard ratio (HR) 2.76, 95% CI: 1.03-7.77, P=0.04].

CONCLUSIONS

In a population of patients undergoing TAVR, MCF ≤30% was independently associated with increased mortality.

Blood Disorders in Patients Undergoing Transcatheter Aortic Valve Replacement: A Review

Transcatheter aortic valve replacement (TAVR) is well established for treating patients with severe aortic stenosis considered at intermediate to high surgical risk. Blood disorders such as anemia, thrombocytopenia, and acquired type 2A von Willebrand disease are relatively frequent in TAVR candidates, and multiple studies to date have highlighted their potential clinical association with mortality and/or bleeding complications post-TAVR. The present review provides an overview of various blood disorders observed pre- and post-TAVR, with special focus on their incidence, etiology, clinical association, and management.

Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement

BACKGROUND

The aim of this study is to analyze sex-specific readmission rates, etiology, and predictors of readmission after transcatheter aortic valve replacement (TAVR). Readmissions after TAVR are common, contributing to increased health care utilization and costs. Many factors have been discovered as predictors of readmission; however, sex-specific disparities in readmission rates are limited.

METHODS

Between January 2012 and September 2015, adult patients after TAVR were identified using appropriate international classifications of diseases, ninth revision, clinical modification from the National Readmission Database. Incidence of unplanned 30-days readmission rate was the primary outcome of this study. In addition, this study includes sex-specific etiology and predictors of readmissions. Multivariate logistic regression was performed to analyze adjusted readmission rates. Hierarchical 2-level logistic models were used to evaluate predictors of readmission.

RESULTS

Readmission rate at 30 days was 17.3%, with slightly higher readmission rates in women (OR 1.09; CI: 1.01-1.19, p < 0.001) after multivariate adjusted analysis. Noncardiac causes were responsible for most readmissions in both genders. Etiologies for readmissions such as arrhythmias, pulmonary complications, and infections were slightly higher in women, whereas heart failure and bleeding complications were higher in men. History of heart failure, atrial fibrillation, prior pacemaker, and renal failure significantly strongly predicted readmissions in both genders.

CONCLUSION

Women undergoing TAVR have slightly higher 30-day all-cause readmission rates. These results indicate that women require more attention compared to men to prevent 30-day readmission. In addition, risk stratification for men and women based on predictors will help identify high-risk men and women for readmissions.

Perioperative poor grip strength recovery is associated with 30-day complication rate after cardiac surgery discharge in middle-aged and older adults - a prospective observational study

BACKGROUND

Although perioperative care during heart surgery has improved considerably, the rate of postoperative complications has remained stable. It has not been concluded how to better apply grip strength to clinical, postoperative complications. So our study aimed at researching the best way for using grip value for predicting early postoperative complications.

METHODS

A total of 212 patients with mean age 63.8 ± 6.3 who underwent cardiac surgery participated in our study. We analyzed the ROC curve of grip strength, grip/weight and grip recovery with complications, found the best cutoff point. Logistic regression confirmed the association between grip strength grouping and complications.

RESULTS

We found that 36 patients had 30-day complications. EuroSCORE were 2.15 ± 1.52 and 2.42 ± 1.58 between normal and complication groups, respectively. The area under the receiver-operating characteristic curve (AUC) of grip recovery take the most area (0.837, p < 0.001), and the cutoff point was 83.92%. In logistic regression, lower grip recovery has higher risk impact on 30-day complications for 25.68 times than normal group, after adjusted surgery-related factors. After regrouped characteristic information by grip recovery cutoff point, we found that percentage of the estimated 6 min walk distance (41.5 vs 48.3, p = 0.028) and hospitalization time (7.2 vs 6.1, p = 0.042) had worse trends in lower recovery group.

CONCLUSIONS

Poor grip recovery may be related to higher risk of postoperative complications within 30 days after discharge in middle-aged and older people independent of surgical risk. The results of this study provide a reference for the development of rehabilitation programs in the early postoperative recovery, and may also be a prognostic indicator for postoperative high-risk groups.

TRIAL REGISTRATION

Our research was registered on Research Registry website, the registry number was ChiCTR1800018465. Date: 2018/9/20. Status: Successful.

Incidence, Clinical Characteristics, and Impact of Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

OBJECTIVES

The authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR.

BACKGROUND

About one-half of the patients undergoing transcatheter aortic valve replacement (TAVR) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown.

METHODS

Consecutive patients undergoing TAVR in our institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction.

RESULTS

A total of 779 patients (mean age 79 ± 9 years, 52% male, mean STS: 6.8 ± 5.1%) were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVR. Clinical presentation was type 2 non-ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non-ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%). Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p = 0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p = 0.001), and nontransfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p = 0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention. In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively.

CONCLUSIONS

Approximately one-tenth of patients undergoing TAVR were readmitted for an ACS after a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach were independent predictors of ACS. ACS was associated with high midterm mortality.

Incidence, 30-day readmission rates and predictors of readmission after new onset atrial fibrillation who underwent transcatheter aortic valve replacement

INTRODUCTION

New onset Atrial Fibrillation (NOAF) is frequently seen post transcatheter aortic valve replacement (TAVR). NOAF in the setting of TAVR has also been recognized as predictor of worse outcomes, including higher readmission rates. Data assessing the effect and predictors of NOAF on 30-day readmission rates post TAVR is limited.

OBJECTIVE

To assess the incidence, 30-day readmission rate and predictors of NOAF in patients who underwent TAVR.

METHODS

Nationwide Readmissions Database was used to identify patients who developed NOAF post-TAVR between 2012 and 2015.

RESULTS

A total of 24,076 patients were included in this study, of which 54% were males, and the mean age was 82.4 ± 7.2. NOAF was developed in 10,847 (45%) patients. Overall readmission rates with NOAF was 19.7% and trend in the readmissions reduced during the course of the study (21.9% to 18.7%, P_trend < 0.001). Thirty-day readmission rate in patients who developed NOAF post-TAVR was significantly higher compared to TAVR patients without NOAF (OR 1.39; 95% CI, 1.28-1.51; p < 0.001). Similarly, rate of ischemic stroke was significantly higher among patients who developed NOAF (OR 1.22; 95% CI, 1.07-1.4; p = 0.004). Predictors of readmissions in NOAF group were mostly non-cardiac, and included age, and comorbidities with chronic liver disease, renal failure and chronic lung disease been the most common comorbidities, in that order.

CONCLUSIONS

Incidence of NOAF is associated with increased risk of readmissions and ischemic stroke. Future research should focus on interventions to prevent avoidable readmissions and associated morbidity and mortality.

Incidence and predictors of readmissions to non-index hospitals after transcatheter aortic valve replacement and the impact on in-hospital outcomes: From the nationwide readmission database

INTRODUCTION

Whether readmission to non-index hospitals (where the initial procedure was not performed) could result in adverse outcomes and increased utilization of healthcare resources compared with readmission to index hospitals after transcatheter aortic valve replacement (TAVR) remains unclear.

METHODS

From January 2012 to September 2015, a nationwide readmission database was queried to identify those who were older than 50 years and had endovascular TAVR, using the International Classification of Disease, 9th Revision, Clinical Modification code 35.05. Elective readmissions were excluded. In-hospital outcomes were compared between the index and non-index hospital readmissions. A multivariable logistic regression analysis was performed to identify predictors of non-index hospital readmissions.

RESULTS

A total of 6808 readmissions were identified of which 2564 (37.7%) were readmitted to non-index hospitals. Residents at smaller counties, metropolitan non-teaching hospitals, or hospitals at large metropolitan areas were predictors of non-index readmissions. In-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.20), acute myocardial infarction (aOR 0.83, p = 0.53), pacemaker placement (aOR 0.97, p = 0.90), acute kidney injury (aOR 0.98, p = 0.84), and stroke (aOR 1.03, p = 0.90) were similar between index and non-index readmissions but bleeding events requiring transfusions were more frequently observed in readmissions at non-index hospitals (aOR 1.32, p = 0.025). Hospital cost (15,410 dollars vs. 16,390 dollars, p = 0.25) and length of stay (5.70 days vs. 5.65 days, p = 0.85) were comparable between groups.

CONCLUSIONS

Non-index readmissions post-TAVR was relatively common but did not result in increased hospital mortality or healthcare utilization. Our results are reassuring for TAVR recipients with limited access to index hospitals.

Relation of Postdischarge Care Fragmentation and Outcomes in Transcatheter Aortic Valve Implantation from the STS/ACC TVT Registry

Fragmented care following elective surgery has been associated with poor outcomes. The association between fragmented care and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. We examined patients who underwent TAVI from 2011 to 2015 at 374 sites in the STS/ACC TVT Registry, linked to Center for Medicare and Medicaid Services claims data. Fragmented care was defined as at least one readmission to a site other than the implanting TAVI center within 90 days after discharge, whereas continuous care was defined as readmission to the same implanting center. We compared adjusted 1-year outcomes, including stroke, bleeding, heart failure, mortality, and all-cause readmission in patients who received fragmented versus continuous care. Among 8,927 patients who received a TAVI between 2011 and 2015, 27.4% were readmitted within 90 days of discharge. Most patients received fragmented care (57.0%). Compared with the continuous care group, the fragmented care group was more likely to have severe chronic lung disease, cerebrovascular disease, and heart failure. States that had lower TAVI volume per Center for Medicare and Medicaid Services population had greater fragmentation. Patients living > 30 minutes from their TAVI center had an increased risk of fragmented care 1.07 (confidence interval [CI] 1.06 to 1.09, p < 0.001). After adjustment for comorbidities and procedural complications, fragmented care was associated with increased 1-year mortality (hazards ratio 1.18, CI 1.04 to 1.35, p = 0.010) and all-cause readmission (hazards ratio 1.08, CI 1.00 to 1.16, p = 0.051. In conclusion, fragmented readmission following TAVI is common, and is associated with increased 1-year mortality and readmission. Efforts to improve coordination of care may improve these outcomes and optimize long-term benefits yielded from TAVI.

Predictors and outcomes of heart failure after transcatheter aortic valve implantation using a self-expanding prosthesis

INTRODUCTION AND OBJECTIVES

The purpose of this analysis was to assess the incidence, predictors and prognostic impact of acute heart failure (AHF) after transcatheter aortic valve implantation (TAVI) using a self-expanding prosthesis.

METHODS

From November 2008 to June 2017, all consecutive patients undergoing TAVI in our center were prospectively included in our TAVI registry. The predictive effect of AHF on all-cause mortality following the TAVI procedure was analyzed using Cox regression models.

RESULTS

A total of 399 patients underwent TAVI with a mean age of 82.4 ± 5.8 years, of which 213 (53.4%) were women. During follow-up (27.0 ± 24.1 months), 29.8% (n = 119) were admitted due to AHF, which represents a cumulative incidence function of 13.2% (95%CI, 11.1%-15.8%). At the end of follow-up, 150 patients (37.59%) had died. Those who developed AHF showed a significantly higher mortality rate (52.1% vs 31.4%; HR, 1.84; 95%; CI, 1.14-2.97; P = .012). Independent predictors of AHF after TAVI were a past history of heart failure (P = .019) and high Society of Thoracic Surgeons score (P = .004). We found that nutritional risk index and chronic obstructive pulmonary disease were strongly correlated with outcomes in the AHF group.

CONCLUSIONS

TAVI was associated with a high incidence of clinical AHF. Those who developed AHF had higher mortality. Pre-TAVI AHF and high Society of Thoracic Surgeons score were the only independent predictors of AHF in our cohort. A low nutritional risk index and chronic obstructive pulmonary disease were independent markers of mortality in the AHF group.

Effect of Baseline Left Ventricular Ejection Fraction on 2-Year Outcomes After Transcatheter Aortic Valve Replacement

Background:

Impaired left ventricular function is associated with worse prognosis among patients with aortic stenosis treated medically or with surgical aortic valve replacement. It is unclear whether reduced left ventricular ejection fraction (LVEF) is an independent predictor of adverse outcomes after transcatheter aortic valve replacement.

Methods and Results:

Patients who underwent transcatheter aortic valve replacement in the PARTNER 2 trials (Placement of Aortic Transcatheter Valves) and registries were stratified according to presence of reduced LVEF (<50%) at baseline, and 2-year risk of cardiovascular mortality was compared using Kaplan–Meier methods and multivariable Cox proportional hazards regression. Of 2991 patients, 839 (28%) had reduced LVEF. These patients were younger, more often males, and were more likely to have comorbidities, such as coronary disease, diabetes mellitus, and renal insufficiency. Compared with patients with normal LVEF, patients with low LVEF had higher crude rates of 2-year cardiovascular mortality (19.8% versus 12.0%, P <0.0001) and all-cause mortality (27.4% versus 19.2%, P <0.0001). Mean aortic valve gradient was not associated with clinical outcomes other than heart failure hospitalizations (hazard ratio [HR], 0.99; CI, 0.99–1.00; P =0.03). After multivariable adjustment, patients with reduced versus normal LVEF had significantly higher adjusted risk of cardiovascular death (adjusted HR, 1.42, 95% CI, 1.11–1.81; P =0.005), but not all-cause death (adjusted HR, 1.20; 95% CI, 0.99–1.47; P =0.07). When LVEF was treated as continuous variable, it was associated with increased 2-year risk of both cardiovascular mortality (adjusted HR per 10% decrease in LVEF, 1.16; 95% CI, 1.07–1.27; P =0.0006) and all-cause mortality (adjusted HR, 1.09; 95% CI, 1.01–1.16; P =0.02).

Conclusions:

In this patient-level pooled analysis of PARTNER 2 patients who underwent transcatheter aortic valve replacement, baseline LVEF was an independent predictor of 2-year cardiovascular mortality.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01314313, NCT02184442, NCT03222128, and NCT02184441.

Derivation and external validation of a simple risk tool to predict 30-day hospital readmissions after transcatheter aortic valve replacement

AIMS

Patients undergoing transcatheter aortic valve replacement (TAVR) possess a higher risk of recurrent healthcare resource utilisation due to multiple comorbidities, frailty, and advanced age. We sought to devise a simple tool to identify TAVR patients at increased risk of 30-day readmission.

METHODS AND RESULTS

We used the Nationwide Readmissions Database from January 2013 to September 2015. Complex survey methods and hierarchical regression in R were implemented to create a prediction tool to determine probability of 30-day readmission. Boot-strapped internal validation and cross-validation were performed to assess model accuracy. External validation was performed using a single-centre data set. Of 39,305 patients who underwent endovascular TAVR, 6,380 (16.2%) were readmitted within 30 days. The final 30-day readmission risk prediction tool included the following variables: chronic kidney disease, end-stage renal disease on dialysis (ESRD), anaemia, chronic lung disease, chronic liver disease, atrial fibrillation, length of stay, acute kidney injury, and discharge disposition. ESRD (OR 2.11, 95% CI: 1.7-2.63), length of stay ≥5 days (OR 1.64, 95% CI: 1.50-1.79), and short-term hospital discharge disposition (OR 1.81, 95% CI: 1.2-2.7) were the strongest predictors. The c-statistic of the prediction model was 0.63. The c-statistic in the external validation cohort was 0.69. On internal calibration, the tool was extremely accurate in predicting readmissions up to 25%.

CONCLUSIONS

A simple and easy-to-use risk prediction tool utilising standard clinical parameters identifies TAVR patients at increased risk of 30-day readmission. The tool may consequently inform hospital discharge planning, optimise transitions of care, and reduce resource utilisation.

Age-dependent morbidity and mortality outcomes after surgical aortic valve replacement

OBJECTIVES

This study addressed the assumption of increased morbidity and mortality after surgical aortic valve replacement in patients older than 80 years with severe aortic stenosis.

METHODS

This prospective study was performed in consecutive patients referred for aortic valve replacement. The age-dependent change in cognitive and physical function, quality of life and rehospitalization and complication rates during the following year and 5-year all-cause mortality were documented.

RESULTS

A total of 351 patients underwent surgical aortic valve replacement. The death risk at 5 years was 10%, 20% and 34% in patients aged <70 years, 70-79 years and ≥80 years, respectively. Patients aged 70-79 years and ≥80 years had a hazard ratio of 1.88 [95% confidence interval (95% CI) 0.92-3.83, P = 0.08] and 2.90 [95% CI 1.42-5.92, P = 0.003] for mortality, respectively, when compared with patients aged <70 years. The length of stay and rehospitalization rate during the following year were similar between the groups. Patients ≥80 years of age experienced more delirium and infections, whereas the risks of new pacemaker, transient ischaemic attack (TIA) or stroke, myocardial infarction and heart failure were comparable between the age groups. All groups exhibited reduced New York Heart Association class, improved physical quality of life and unchanged mental scores without any clinically significant Mini Mental Status reduction.

CONCLUSIONS

Elderly patients (≥80 years of age) have important gains in health measures and satisfactory 5-year survival with an acceptable complications rate during the year following surgery. Active respiratory mobilization and the removal of an indwelling urethra catheter can prevent adverse effects, and measures should be taken to prevent delirium and confusion in elderly patients.

Clinical trial registration

clinicaltrials.gov (NCT 01794832).

Predictors and Risk Calculator of Early Unplanned Hospital Readmission Following Contemporary Self-Expanding Transcatheter Aortic Valve Replacement from the STS/ACC TVT Registry

BACKGROUND

Predictors of hospital readmissions and tools to predict readmissions after TAVR are scarce. Our objective was to identify predictors of early hospital readmission following TAVR in contemporary clinical practice and develop a risk calculator.

METHODS

Patients with a contemporary self-expanding TAVR between 2015 and 2017 in the STS/ACC/TVT Registry™ database were included. Patients were divided into a derivation and validation cohort (2:1). A risk score was calculated using the derivation cohort based on multivariable predictors of 30-day unplanned readmissions and applied to the validation cohort.

RESULTS

A total of 10,345 TAVR patients at 350 centers were included. Unplanned 30-day hospital readmission was 9.2%. Patients with an early readmission had higher 30-day rates for mortality (2.3% vs. 0.8%, p ≪ 0.001), stroke (4.1% vs. 2.7% p = 0.009), major vascular complications (2.0% vs. 1.0%, p = 0.003) and new pacemaker implantation (25.7% vs. 18.6%, p ≪ 0.001). Multivariable predictors of 30-day readmission included diabetes, atrial fibrillation, advanced heart failure symptoms, home oxygen, decreased 5-m gait speed or the inability to walk, serum creatinine ≫1.6 mg/dL, index hospitalization length of stay ≫5 days, major vascular complication and ≥ moderate post-procedure aortic or mitral valve regurgitation. Based on these predictors, we stratified 30-day readmission risk into low-, moderate- and high-risk subsets. There was a 2.5× difference in readmission rates between the low- (5.8%) and high-risk subsets (14.6%).

CONCLUSION

We stratified the risk of early hospital readmission after TAVR based on a simple scoring system. This score may improve discharge planning centered on the individual's readmission risk.

SUMMARY

Unplanned readmissions in the United States are prevalent and costly accounting for $41.3 billion in annual hospital payments and are associated with adverse clinical outcomes. We found that diabetes, atrial fibrillation, advanced heart failure symptoms, home oxygen, frailty, acute kidney injury, prolonged hospitalization, major vascular complications, and moderate or worse post-procedure aortic or mitral valve regurgitation predicted of 30-day readmission following self-expanding TAVR. This information may improve discharge planning centered on each patient's readmission risk.

Profiling Hospital Performance on the Basis of Readmission After Transcatheter Aortic Valve Replacement in Ontario, Canada

Background

Readmission rates are a widely accepted quality indicator. Our objective was to develop models for calculating case‐mixed adjusted readmission rates after transcatheter aortic valve replacement for the purpose of profiling hospitals.

Methods and Results

In this population‐based study in Ontario, Canada, we identified all transcatheter aortic valve replacement procedures between April 1, 2012, and March 31, 2016. For each hospital, we first calculated 30‐day and 1‐year risk‐standardized (predicted versus expected) readmission rates, using 2‐level hierarchical logistic regression models, including clustering of patients within hospitals. We also calculated the risk‐adjusted (observed versus expected) readmission rates, accounting for the competing risk of death using a Fine‐Gray competing risk model. We categorized hospitals into 3 groups: those performing worse than expected, those performing better than expected, or those performing as expected, on the basis of whether the 95% CI was above, below, or included the provincial average readmission rate respectively. Our cohort consisted of 2129 transcatheter aortic valve replacement procedures performed at 10 hospitals. The observed readmission rate was 15.4% at 30 days and 44.2% at 1 year, with a range of 10.9% to 21.7% and 38.8% to 55.0%, respectively, across hospitals. Incorporating the competing risk of death translated into meaningful different results between models; as such, we concluded that the risk‐adjusted readmission rate was the preferred metric. On the basis of the 30‐day risk‐adjusted readmission rate, all hospitals performed as expected, with a 95% CI that included the provincial average. However, we found that there was significant variation in 1‐year risk‐adjusted readmission rate.

Conclusions

There is significant interhospital variation in 1‐year adjusted readmission rates among hospitals, suggesting that this should be a focus for quality improvement efforts in transcatheter aortic valve replacement.

Endovascular Versus Transapical Transcatheter Aortic Valve Replacement: In-hospital Mortality, Hospital Outcomes, and 30-day Readmission. A Propensity Score-matched Analysis

INTRODUCTION

Transapical transcatheter aortic valve replacement (TAVR) is associated with increased morbidity compared with endovascular TAVR. We sought to compare the differences in clinical outcomes between endovascular and transapical TAVR approaches utilizing a propensity score model.

METHODS

Patients undergoing TAVR (International Classification of Diseases, Ninth Revision, Clinical Modification codes 35.05 and 35.06) between January 2011 and November 2014 were identified in the Nationwide Readmissions Database, and a propensity score-matched analysis was performed comparing transapical versus endovascular approach. The primary outcome of interest was in-hospital mortality and 30-day all-cause readmission. We also evaluated trends in use of TAVR over the years.

RESULTS

We identified 28,302 endovascular TAVR and 7967 transapical TAVR performed during the study period. The propensity score-matching algorithm yielded 7879 well-matched patients in each group. The in-hospital mortality rates were significantly lower in endovascular TAVR compared with transapical TAVR (1.7% vs 6.7%; OR, 0.24; 95% CI, 0.17- 0.35; P < 0.001). The 30-day readmission rate was lower in endovascular TAVR (14.4% vs 16.8%; OR, 0.83; 95% CI, 0.70-0.98; P = 0.036). Use of TAVR increased from 585 (74% endovascular TAVR) in 2011 to 16,801 in 2014 (82.8% endovascular TAVR).

CONCLUSIONS

Endovascular TAVR is associated with significantly lower in-patient mortality and lower readmission rate when compared with transapical TAVR. Heart failure remains the most common cause for readmission after TAVR regardless of approach.

Physical performance as a predictor of midterm outcome after mitral valve surgery

The usefulness of performing physical function assessments for evaluating clinical outcomes after all cardiac surgeries has been reported. However, no studies have evaluated the relationship between physical function and prognosis in patients undergoing cardiac open surgery with mitral valve regurgitation (MR). This study investigated whether physical assessment, such as the short physical performance battery (SPPB), could predict unplanned readmission events in patients undergoing mitral valve surgery due to MR. SPPB could predict unplanned admission events in patients undergoing mitral valve surgery due to MR. This retrospective study included 168 patients who underwent mitral valve surgery. SPPB was performed 1.6 ± 1.1 days before surgery. The primary endpoint was unplanned readmission. The mean follow-up period was 762 ± 480 days, mean age was 73.8 ± 6.3 years, and 43% of the patients were women. Of the study patients, 46 required unplanned readmissions; 29 of these patients required readmissions within 1 year. Multivariate Cox regression analysis demonstrated that SPPB was independently associated with the primary endpoint. Receiver-operating characteristic analysis showed that SPPB had an area under the curve of 0.71, with an optimal cutoff of 11. The study patients were stratified into SPPB 12 or SPPB ≤ 11 groups. Kaplan-Meier analysis showed that the event-free rate was significantly lower in the SPPB ≤ 11 group (hazard ratio 3.8, 95% confidence interval 2.1-7.0; p < 0.001). SPPB was a useful tool for predicting unplanned readmission in patients undergoing mitral valve surgery due to MR.

Impact of oral anticoagulants on 30-day readmission: a study from a single academic centre

Researchers are extensively searching for modifiable risk factors including high-risk medications such as anticoagulation to avoid rehospitalisation. The influence of oral anticoagulant therapy on hospital readmission is not known. We investigated the impact of warfarin and direct oral anticoagulants (DOACs) on all cause 30-day hospital readmission retrospectively in an academic centre. We study the eligible cohort of 1781 discharges over 2-year period. Data on age, gender, diagnoses, 30-day hospital readmission, discharge medications and variables in the HOSPITAL score (Haemoglobin level at discharge, Oncology at discharge, Sodium level at discharge, Procedure during hospitalisation, Index admission, number of hospital Admissions, Length of stay) and LACE index (Length of stay, Acute/emergent admission, Charlson comorbidity index score, Emergency department visits in previous 6 months), which have higher predictability for readmission were extracted and matched for analysis. Warfarin was the most common anticoagulant prescribed at discharge (273 patients) with a readmission rate of 20% (p<0.01). DOACs were used by 94 patients at discharge with a readmission rate of 4% (p=0.219). Multivariate logistic regression showed an increased risk of readmission with warfarin therapy (OR 1.36, p=0.045). Logistic regression did not show DOACs to be a risk factor for hospital readmission. Our data suggests that warfarin therapy is a risk factor for all-cause 30-day hospital readmission. DOAC therapy is not found to be associated with a higher risk of hospital readmission. Warfarin anticoagulation may be an important target for interventions to reduce hospital readmissions.

Association between transitional care factors and hospital readmission after transcatheter aortic valve replacement: a retrospective observational cohort study

Background

Studies have shown that patients who undergo trans-catheter aortic valve replacement (TAVR) have high rates of hospital readmission. Our objectives were to identify the causes of readmission after TAVR, determine whether transitional care factors were associated with a reduction in readmission and to identify other predictors that could be used to target quality improvement efforts.

Methods

We conducted a chart abstraction study that included all patients who underwent TAVR in Ontario, Canada between 2007 and 2013 and survived to hospital discharge. These data were linked to provincial administrative databases. The association between transitional care factors (home care, rehabilitation, family physician and cardiologist follow-up) and 1-year hospital readmission was examined using a time-to-event analysis. Cause-specific hazards models were used to account for the competing risk of death.

Results

There were 937 patients in the cohort and the rate of readmission at 1-year was 49%. The most common causes of readmission were heart failure and bleeding. Rehabilitation (HR 1.34, 95% CI 1.11–1.62; p = 0.002) and cardiologist follow-up (HR 1.41, 95% CI 1.14–1.75; p = 0.002) were both associated with higher readmission rates. While, home care (HR 1.18, 95% CI 0.96–1.44; p = 0.12) and family physician follow-up (HR 1.04, 95% CI 0.85–1.28; p = 0.71) were not associated with readmission.

Conclusion

Readmission post TAVR is common; however, we did not identify any transitional care factors associated with reductions in hospital readmission. This suggests ongoing research is required to identify targets for improvement in post-procedural care.

Neutrophil-to-lymphocyte ratio predicts heart failure readmissions and outcomes in patients undergoing transcatheter aortic valve replacement

OBJECTIVE

Neutrophil-to-lymphocyte ratio (NLR) has prognostic value in acute coronary syndromes. We investigated its utility for predicting heart failure (HF) admissions and major adverse cardiac outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Data on clinical, laboratory, procedural, HF admissions, and major adverse cardiac events (MACEs) (all-cause mortality, recurrence of myocardial infarction requiring intervention, stroke) for 298 consecutive patients who underwent TAVR between 2012 and 2016 in our tertiary center were collected.

RESULTS

Analysis included 298 patients. The mean age was 83 ± 8 years, 51% were males, and 95% were Caucasians. The median Society of Thoracic Surgeons risk score was 9 (interquartile range: 6.3-11.8). Receiver-operating curve analysis identified a cutoff value of NLR of 4.0 for MACE after TAVR and sensitivity of 68% and specificity of 68% {area under the curve [AUC] = 0.65 [95% confidence interval (CI): 0.51-0.79], p = 0.03}. An NLR of 4.0 for HF hospitalizations after TAVR and sensitivity of 60% and specificity of 57% [AUC = 0.61 (95% CI: 0.53-0.69), p = 0.01]. NLR ≥4.0 before TAVR significantly predicted MACE after TAVR (68.4% vs. 31.6%, p = 0.02) and HF hospitalizations (58.3% vs. 41.7%, p = 0.03). NLR with TAVR risk score increased the predictive value for MACE after TAVR from AUC = 0.61 (95% CI: 0.50-0.72, p = 0.06) to AUC = 0.69 (95% CI: 0.57-0.80, p = 0.007).

CONCLUSION

NLR predicts all-cause mortality, MACE, and HF hospitalization 1 year after TAVR. NLR with TAVR risk score improved predictability for MACE. Further studies for prognostication using NLR are warranted.

The Relationship Between Heart-Failure Hospitalization and Mortality in Patients Receiving Transcatheter Aortic Valve Replacement

BACKGROUND

Patients who have had transcatheter aortic valve replacement (TAVR) are at risk of hospitalization during the first year postprocedure. Few studies have examined the incidence of heart- failure hospitalizations (HFH) post-TAVR and the impact this has on subsequent hospitalizations and mortality. Our aim was to determine the incidence, predictors, and mortality associated with HFH post-TAVR.

METHODS

We used prospectively collected data for all patients who underwent TAVR between August 1, 2010, and March 31, 2015; 742 consecutive patients who underwent TAVR during the study period were included. Patients were followed for a minimum of 1 year post-TAVR.

RESULTS

Mean age was 80.9 ± 8.1, and 58.2% were men. Hospitalizations post-TAVR occurred in 20% of patients at 30 days and 59.7% at 1 year. Of patients hospitalized, HFH was the primary cause of hospitalization in 25.8% and 21.4% of patients at 30 days and 1 year post-TAVR, respectively. Patients with HFH at either 30 days or 1 year had higher subsequent rates of rehospitalization compared with patients who had non-HFH. Patients with HFH or non-HFH at 30 days had 1-year mortality rates of 23.1% and 21.4%, respectively, whereas those with HFH by 1 year had a higher 1-year rate of mortality compared with patients who had non-HFHs (25% vs 10.9%, P < 0.001).

CONCLUSIONS

HF accounts for a quarter of all hospitalizations post-TAVR and is associated with higher rates of subsequent rehospitalization and death compared with those who had non-HFH. Understanding predictors of readmissions post-TAVR will allow for better risk stratification and improve outcomes in patients receiving TAVR.

Comparison of Causes and Associated Costs of 30-Day Readmission of Transcatheter Implantation Versus Surgical Aortic Valve Replacement in the United States (A National Readmission Database Study)

Our current knowledge about comparative differences in 30-day readmissions and the impact of readmissions on overall costs after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is largely derived from clinical trials. The objectives of this study were to compare readmissions and costs for TAVI and SAVR in a nationally representative population-based sample. The Healthcare Cost and Utilization Project's National Readmission Database was used for the study. Hierarchical multivariable regression analyses were used to examine differences in the propensity score 1:1 matched cohort. The matched cohort included 4,682 patients who survived index procedures done from January through November 2013. Compared with SAVR, the rate of 30-day readmission was not significantly different for endovascular TAVI (16% vs 18%; p = 0.19); and was higher for the transapical TAVI (22% vs 17%; p <0.01) group. The 30-day cumulative costs were higher for the 2 endovascular TAVI ($51,025 vs $46,228; p = 0.03) and transapical TAVI ($59,575 vs $45,792; p <0.01). In multivariable analyses, the risk of 30-day readmission was similar for endovascular TAVI (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.78 to 1.12) and was 27% higher for transapical TAVI (OR 1.27; 95% CI 1.02 to 1.57). Cumulative costs (index plus readmission costs) were 13% (β 0.13; 95% CI 0.10 to 0.15) and 19% (β 0.19; 95% CI 0.16 to 0.23) higher for the endovascular TAVI and transapical TAVI, respectively. In conclusion, the rate of readmissions was similar for endovascular TAVI and SAVR but the costs were 26% higher for TAVI than for SAVR.

Impact of Frailty Markers for Unplanned Hospital Readmission Following Transcatheter Aortic Valve Implantation

BACKGROUND

Various frailty markers have been developed to guide better patient selection for transcatheter aortic valve implantation (TAVI). This study aimed to investigate the frequency and specific causes of unplanned hospital readmission after TAVI, and to investigate which frailty markers better predicted outcomes.

METHODS AND RESULTS

We retrospectively reviewed 155 patients for whom we calculated their Short Physical-Performance Battery (SPPB), Placement of AoRTic TraNscathetER Valve (PARTNER) frailty scale, frailty index, clinical frailty scale, modified Fried scale, and gait speed. The primary endpoint was unplanned readmission following TAVI. The clinical model was established using variables that were identified as independent predictors in multivariate analysis. Incremental values were assessed after adding each frailty marker to the clinical model, and were compared between frailty markers. Although unplanned readmission <30 days was 1.9%, 23% of patients had an unplanned readmission following TAVI mainly because of heart failure and pneumonia within 1 year. Frailty markers other than the modified Fried scale were independently associated with unplanned readmission. The SPPB and the PARTNER frailty scale significantly increased discriminatory performance for predicting unplanned readmission.

CONCLUSIONS

Unplanned readmissions following TAVI in the present study were fewer than previously reported. There seems to be a difference between frailty markers in their predictive performance. Precise frailty assessment may result in reducing unplanned admissions after TAVI and therefore better quality of life.

Hospital readmission following transcatheter aortic valve implantation in the real world

BACKGROUND

There is limited data on hospital readmissions following transcatheter aortic valve implantation (TAVI). The aim of this study was to investigate hospital readmissions post-TAVI.

METHODS

Data from the Optimized transCathEter vAlvular iNtervention (OCEAN-TAVI) multicenter registry (registration no. UMIN000020423) were collected from 1215 patients who underwent TAVI. Incidence, timing, causes, and predictors of readmission in addition to the impact on patient outcomes were analyzed.

RESULTS

Of 1215 patients, 223 (18.4%) were readmitted within 1 year post-TAVI. Early readmission (≤30 days) occurred in 42 patients, while late readmission (>30 days) occurred in 181 patients. Readmissions were due to cardiac disorders, such as heart failure and arrhythmia, in 77 patients and non-cardiac disorders, such as respiratory disorders, infections, and cerebrovascular events, in 146 patients. Kaplan-Meier analysis revealed that early readmission was associated with a lower 1-year survival compared to non-early readmission (72.4% vs. 89.0%, p < 0.05). Multivariate Cox regression analysis showed that acute kidney injury (hazard ratio [HR], 2.27; p = 0.03) was an independent predictor of early readmission, while anemia (HR, 2.21; p < 0.01), hypoalbuminemia (HR, 1.37; p = 0.04), atrial fibrillation (HR, 1.70; p < 0.01), and more than mild postprocedural aortic regurgitation (HR, 1.62; p < 0.01) were independent predictors of late readmission.

CONCLUSION

Readmission occurred in approximately one-fifth of patients post-TAVI and was associated with poor patient outcomes. Early readmission was mainly due to procedural complications, while late readmission was mainly determined by baseline comorbidities including a frailty criterion. Measures should be taken to reduce hospital readmissions and improve patient outcomes post-TAVI.

Risk factors and direct medical cost of early versus late unplanned readmissions among diabetes patients at a tertiary hospital in Singapore

OBJECTIVE

To examine the risk factors and direct medical costs associated with early (≤30 days) versus late (31-180 days) unplanned readmissions among patients with type 2 diabetes in Singapore.

METHODS

Risk factors and associated costs among diabetes patients were investigated using electronic medical records from a local tertiary care hospital from 2010 to 2012. Multivariable logistic regression was used to identify risk factors associated with early and late unplanned readmissions while a generalized linear model was used to estimate the direct medical cost. Sensitivity analysis was also performed.

RESULTS

A total of 1729 diabetes patients had unplanned readmissions within 180 days of an index discharge. Length of index stay (a marker of acute illness burden) was one of the risk factors associated with early unplanned readmission while patient behavior-related factors, like diabetes-related medication adherence, were associated with late unplanned readmission. Adjusted mean cost of index admission was higher among patients with unplanned readmission. Sensitivity analysis yielded similar results.

CONCLUSIONS

Existing routinely captured data can be used to develop prediction models that flag high risk patients during their index admission, potentially helping to support clinical decisions and prevent such readmissions.

Utilization, In-Hospital Mortality, and 30-Day Readmission After Percutaneous Mitral Valve Repair in the United States Shortly After Device Approval

The MitraClip device for percutaneous mitral valve repair was approved by the Food and Drug Administration in the United States in October 2013. Few studies have evaluated national outcomes after this procedure in routine clinical practice. We identified adults aged ≥18 years who received percutaneous mitral valve repair from November 2013 to December 2014 in the Nationwide Readmissions Database, a publicly available administrative claims database. Procedural volumes, number of performing hospitals, individual hospital volumes, in-hospital mortality rate, and 30-day hospital readmission rate were determined. Patient demographics, clinical comorbidities, and hospital characteristics were analyzed using logistic regression to determine risk factors for in-hospital death and 30-day readmission. We identified 879 cases performed in the first 14 months after device approval (mean age ± SD, 75.0 ± 13.1 years; 45% women). The number of performing hospitals increased by 5.7-fold (23 to 132), although mean individual hospital volumes remained small (6.2 ± 10.4 cases per hospital). In-hospital all-cause mortality was 3.3% and was associated with higher number of clinical comorbidities. The rate of 30-day readmission was 14.6%, and 6.6% of patients died during rehospitalization. Increased procedural experience was associated with a nonsignificant trend toward reduced hospital readmission after multivariable adjustment (p = 0.08). In conclusion, use of percutaneous mitral valve repair in the United States early after approval increased steadily over time, although individual hospital volumes remained low. More than 1 in 7 patients who underwent this procedure are readmitted within 30 days of discharge.

Rates and predictors of hospital readmission after transcatheter aortic valve implantation

Aims

To analyse reasons, timing and predictors of hospital readmissions after transcatheter aortic valve implantation (TAVI).

Methods and results

Patients included in the Bern TAVI Registry between August 2007 and June 2014 were analysed. Fine and Gray competing risk regression was used to identify factors predictive of hospital readmission within 1 year after TAVI with bootstrap analysis for internal validation. Of 868 patients alive at discharge, 221 (25.4%) were readmitted within 1 year. Compared with patients not requiring readmission, those with at least one readmission more frequently were male and more often had atrial fibrillation and higher creatinine values (P < 0.05 for all cases). For overall 308 readmissions, cardiovascular causes accounted for 46.1% with heart failure as the most frequent indication; non-cardiovascular readmissions occurred for surgery (11.7%), gastrointestinal disorders (9.7%), malignancy (4.9%), respiratory diseases (4.6%) and chronic kidney failure (2.6%). Male gender (subhazard ratio, SHR, 1.33, 95% confidence intervals, CI, 1.02-1.73, P = 0.035) and stage 3 kidney injury (SHR 2.04, 95% CI 1.12-3.71, P = 0.021) were found independent risk factors for any hospital readmission, whereas previous myocardial infarction (SHR 1.88, 95% CI 1.22-2.90, P = 0.004) and in-hospital life-threatening bleeding (SHR 2.18, 95%CI 1.24-3.85, P = 0.007) were associated with cardiovascular readmissions. The event rate for mortality was significantly increased after readmissions for any cause (RR 4.29, 95% CI 2.86-6.42, P < 0.001).

Conclusion

Hospital readmission was observed in one out of four patients during the first year after TAVI and was associated with a significant increase in mortality.

Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes

Interventions focused on ensuring safe transitions for patients from hospital to home can assist in providing continuity of care, preventing readmissions, and reducing duplication of services. Patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) procedure are often frail, elderly, and have multiple co-morbidities. A pilot initiative evaluating transitional care strategies through telephone follow up was implemented in a tertiary centre with the aim to identify gaps and intervene, preventing re-admission and improving patient outcomes. TAVI patients or caregivers were contacted at 3 days and 30 days post discharge by an Advanced Practice Nurse (APN). Telephone follow up centered on best practices for transitional care. Outcomes revealed fluid balance monitoring, medication management, and feelings of anxiety and depression post TAVI were the most frequent areas requiring intervention. Findings from this initiative reinforce the need to establish consistent processes that support elderly patient populations during potentially vulnerable points in the care trajectory.