In‐hospital outcomes of transcatheter versus surgical aortic valve replacement in non‐teaching hospitals

Temporal trends in outcomes following inpatient transcatheter aortic valve replacement

INTRODUCTION

Despite the growing adoption of transcatheter aortic valve replacement (TAVR), there remains a lack of clinical data evaluating procedural safety and discharge practices.

AIMS

This study aims to investigate if there have been improvements in postoperative clinical outcomes following TAVR.

METHODS

In this large-scale, retrospective cohort study, patients who underwent TAVR as an inpatient were identified from 2016 to 2020 using the National Readmissions Database. The primary outcome was temporal trends in the rates of discharge to home. Secondary endpoints assessed annual discharge survival rates, 30-day readmissions, length of stay, and periprocedural cardiac arrest rates.

RESULTS

Over the 5-year study period, a total of 31,621 inpatient TAVR procedures were identified. Of these, 79.2 % of patients were successfully discharged home with home disposition increasing year-over-year from 74.5 % in 2016 to 85.9 % in 2020 (Odds ratio: 2.01; 95 % CI 1.62-2.48, p < 0.001). The mean annual discharge survival rate was 97.7 % which did not change significantly over the 5-year study period (p = 0.551). From 2016 to 2020, 30-day readmissions decreased from 14.0 % to 10.3 %, respectively (p = 0.028). Perioperative cardiac arrest occurred in 1.8 % (n = 579) of cases with rates remaining unchanged during the study (p = 0.674).

CONCLUSION

Most TAVR patients are successfully discharged alive and home, with decreasing 30-day readmissions observed over recent years. This data suggests potential improvements in preoperative planning, procedural safety, and postoperative care. Despite perioperative cardiac arrest being associated with high mortality, it remains a relatively rare complication of TAVR.

Clinical Outcomes Associated With Balloon Aortic Valvuloplasty in the Contemporary Era

BACKGROUND

Severe aortic stenosis is the most common acquired valvular disorder. Balloon aortic valvuloplasty (BAV) is considered for patients who are not suitable for surgical aortic valve replacement (SAVR) and transcatheter aortic valve insertion (TAVI). The American Heart Association and European Society of Cardiology recommend BAV as a bridging procedure for SAVR and TAVI due to the significant morbidity and mortality associated with it. We aim to investigate the morbidity and mortality associated with BAV only, BAV bridged to TAVI and TAVI-only patients over 3 years in Epworth Richmond, a tertiary hospital in Victoria, Australia.

METHODS

We divided patients into three groups including BAV only, BAV bridged to TAVI and TAVI only and assessed the baseline demographics, procedural complications, and mortality between the groups.

RESULTS

Of 438 patients, 26 patients underwent BAV only, 36 patients bridged to TAVI post-BAV and 376 patients underwent TAVI directly. All patients had significant reductions in their mean AV pressure gradient (p<0.01). There was no significant difference in periprocedural morbidity and mortality between the groups. At 6-month follow-up, the mortality in patients undergoing only BAV was 31%, compared with 8.3% in BAV bridged to TAVI and 1.9% in TAVI-only group (p<0.01). The 12-month follow-up demonstrated a similar pattern; 42.3% vs 13.9% vs 4.5% (p<0.01).

CONCLUSIONS

This study suggests no significant difference in inpatient and periprocedural morbidity and mortality between the three groups but a significant mortality benefit at 6-month and 12-month post valve insertion, either directly or post BAV.

Sex Differences in Ischemic Stroke Readmission Rates and Subsequent Outcomes After Coronary Artery Bypass Graft Surgery

BACKGROUND AND PURPOSE

Prior studies examining sex-related risk of readmission for ischemic stroke (IS) after coronary artery bypass grafting (CABG) did not adjust for preoperative comorbidities and used small study samples that were single-center or otherwise poorly generalizable. We assessed risk of readmission for IS after CABG for females compared to males in a nationwide sample.

METHODS

The 2013 Nationwide Readmissions Database contains data on 49% of all U.S. hospitalizations. We used population weighting to determine national estimates. Using all follow-up data up to 1 year after discharge from CABG hospitalization, we estimated Kaplan-Meier cumulative risk of IS, stratified by sex, using the log-rank test for significance. We created Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for IS readmission, with sex as the main independent variable. We ran unadjusted models and models adjusted for age, vascular risk factors, estimated severity of illness and risk of mortality, hospital characteristics, and income quartile of patient's zip code.

RESULTS

An estimated 53,270 females and 147,396 males survived index CABG admission in 2013. There was a consistently elevated cumulative risk of readmission for IS after CABG for females versus males (log-rank p-value = 0.0014). In the unadjusted Cox model, the HR of IS in females vs. males was 1.35 (95% CI 1.12-1.62, p = 0.0015). The elevated risk for females remained after adjusting for severity of illness (1.30 [1.08-1.56], p = 0.0056) and risk of mortality (1.28 [1.07-1.54], p = 0.0086). This elevated risk persisted after adjusting for multiple vascular risk factors, hospital characteristics, and income quartile of patient's zip code (1.23 [1.02-1.48], p = 0.03).

CONCLUSIONS

We found a 23% increased risk of readmission for IS up to 1 year after CABG for females compared to males in a fully adjusted model utilizing a large, contemporary, nationwide database. Further research would clarify mechanisms of this increased risk among women.

The Outcomes of Pulmonary Hypertension Patients With Severe Aortic Stenosis Who Underwent Surgical Aortic Valve Replacement or Transcatheter Aortic Valve Implantation

The outcomes for patients who undergo transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) with pulmonary hypertension (PH) is not well understood. We sought to evaluate the outcomes of patients with PH who underwent TAVI compared with SAVR. We identified patients who were diagnosed with PH and underwent TAVI SAVR for aortic valve stenosis in the National Inpatient Sample database who were admitted from 2011 to 2014. Propensity score matching was used to generate 2 matched cohorts for TAVI and SAVR and outcomes were compared using logistic regressions. A total of 36,786 patients were diagnosed with PH and had an intervention for aortic valve stenosis. Twenty six percent underwent TAVI (n = 9,560) and 74% underwent SAVR (n = 27,225). Patients in the TAVI group were older (81.0 vs 68.5, p <0.001) had more women (53.2% vs 45.4%) and less African-American patients (4.6% vs 8.3%; p <0.001 for both). Although both groups had comparable co-morbidities, the TAVI group had higher prevalence of congestive heart failure, chronic pulmonary disease, renal failure, peripheral vascular disease, coronary artery disease, and previous stroke compared with the SAVR group (p ≤0.002). After propensity-score-matching, patients with PH had no statistically significant difference in in-hospital mortality between for TAVI or SAVR procedures (5.6% vs 4.6%, odds ratio [OR] 1.23, confidence interval [CI] 0.92 to 1.66, p = 0.165). However, TAVI patients were less likely to have cardiac complications (15.4% vs 19.9%, OR 0.73, CI 0.61 to 0.87, p = 0.001) and respiratory complications (12.4% vs 25.1%, OR 0.42, CI 0.35 to 0.51, p <0.001). In conclusion, whereas patient with PH who underwent TAVI and SAVR had similar in-hospital mortality, TAVI was associated with lower cardiac, respiratory and bleeding complications compared with SAVR.