Incidence, Causes, and Impact of In-Hospital Infections After Transcatheter Aortic Valve Implantation

Analysis of risk factors for systemic inflammatory response syndrome in patients after transcatheter aortic valve replacement

OBJECTIVE

Our aim was to determine the risk factors of postoperative systemic inflammatory response syndrome (SIRS) in patients with transcatheter aortic valve replacement (TAVR), identify those with a high risk of SIRS, and help reduce SIRS occurrence.

METHODS

A retrospective cohort study was conducted to collect the clinical data of patients who underwent TAVR from January 2014 to December 2019 at a tertiary hospital in Zhejiang Province. The study included 156 men and 94 women. Patients were divided into SIRS and non-SIRS groups. The pre-, intra-, and postoperative indices of the two groups were recorded. The data of the two groups were compared, and univariate analysis was performed. All statistically significant factors were assessed using binary logistic regression analysis to clarify the risk factors of SIRS after TAVR.

RESULTS

Overall, 30 patients developed SIRS after TAVR, with an incidence rate of 12%, an odds ratio (OR) of 0.571, and a 95% confidence interval (CI) of 0.469-0.694 (p = 0.000). There was a significant correlation between SIRS and glucose (OR: 0.823, 95% CI: 0.678-1.000, p = 0.049), albumin (OR: 0.938, 95% CI: 0.881-0.998, p = 0.044), brain natriuretic peptide (OR: 1.000, 95% CI: 1.000-1.000, p = 0.010), sex (OR: 0.412, 95% CI: 0.190-0.892, p = 0.025), and history of hypertension (OR: 0.375, 95% CI: 0.169-0.819, p = 0.014). Multivariate regression analysis demonstrated that age (OR: 1.190, 95%CI: 1.073-1.319, p = 0.001) and body mass index (BMI; OR: 0.559, 95% CI: 0.447-0.698, p = 0.000) were independent risk factors for postoperative SIRS in patients with TAVR.

CONCLUSION

The incidence of SIRS after TAVR was 12%. There was a significant correlation between SIRS and albumin, glucose, and hypertension. The independent risk factors for SIRS after TAVR were age and BMI.

Infective Endocarditis after Transcatheter Aortic Valve Replacement: Challenges in the Diagnosis and Management

Although initially conceived for high-risk patients who are ineligible for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) is now recommended in a wider spectrum of indications, including among young patients. However, similar to SAVR, TAVR is also associated with a risk of infectious complications, namely, prosthetic valve endocarditis (PVE). As the number of performed TAVR procedures increases, and despite the low incidence of PVE post-TAVR, clinicians should be familiar with its associated risk factors and clinical presentation. Whereas the diagnosis of native valve endocarditis can be achieved straightforwardly by applying the modified Duke criteria, the diagnosis of PVE is more challenging given its atypical symptoms, the lower sensitivity of the criteria involved, and the low diagnostic yield of conventional echocardiography. Delay in proper management can be associated with increased morbidity and mortality. Therefore, clinicians should have a high index of suspicion and initiate proper work-up according to the severity of the illness, the underlying host, and the local epidemiology of the causative organisms. The most common causative pathogens are Gram-positive bacteria such as Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp., and Streptococcus spp. (particularly the viridans group), while less-likely causative pathogens include Gram-negative and fungal pathogens. The high prevalence of antimicrobial resistance complicates the choice of therapy. There remain controversies regarding the optimal management strategies including indications for surgical interventions. Surgical assessment is recommended early in the course of illness and surgical intervention should be considered in selected patients. As in other PVE, the duration of therapy depends on the isolated pathogen, the host, and the clinical response. Since TAVR is a relatively new procedure, the outcome of TAVR-PVE is yet to be fully understood.

Risk Factors for Hospital Readmission Post-Transcatheter Aortic Valve Implantation in the Contemporary Era: A Systematic Review

Background

Despite transcatheter aortic valve implantation (TAVI) becoming a widely accepted therapeutic option for the management of aortic stenosis, post-procedure readmission rates remain high. Rehospitalization is associated with negative patient outcomes, as well as increased healthcare costs, and has therefore been identified as an important target for quality improvement. Strategies to reduce the post-TAVI readmission rate are needed but require the identification of patients at high risk for rehospitalization. Our systematic review aims to identify predictors of post-procedure readmission in patients eligible for TAVI.

Methods

We conducted a comprehensive search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for the time period from 2015 to the present for articles evaluating risk factors for rehospitalization post-TAVI with a follow-up period of at least 30 days in adults age ≥ 70 years with aortic stenosis. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. We present the results as a qualitative narrative review.

Results

We identified 49 studies involving 828,528 patients. Post-TAVI readmission is frequent, and rates vary (14.9% to 54.3% at 1 year). The most-frequent predictors identified for both 30-day and 1-year post-TAVI readmission are atrial fibrillation, lung disease, renal disease, diabetes mellitus, in-hospital life-threatening bleeding, and non-femoral access.

Conclusions

This systematic review identifies the most-common predictors for 30-day and 1-year readmission post-TAVI, including comorbidities and potentially modifiable procedural approaches and complications. These predictors can be used to identify patients at high-risk for readmission who are most likely to benefit from increased support and follow-up post-TAVI.

Budget impact analysis of transcatheter aortic valve replacement in low, intermediate, and high-risk patients with severe aortic stenosis in Saudi Arabia

AIMS

A budget impact analysis (BIA) comparing transcatheter aortic valve replacement (TAVR) with SAPIEN 3 and surgical aortic valve replacement (SAVR) for severe, symptomatic aortic stenosis among patients of low, intermediate, and high surgical risk from the perspective of the public and private sectors in Saudi Arabia.

MATERIALS AND METHODS

A Markov model was developed with six states to calculate the budget impact from time of either TAVR or SAVR intervention up to 5 years. We compared the budget effects of new permanent pacemaker implantation (PPI), new onset atrial fibrillation (AF), major/disabling stroke (MDS), and surgical site infections (SSI). One-way sensitivity analyses (OWSA) were performed on cost and probability inputs.

RESULTS

Analysis of the base case parameters suggests TAVR vs. SAVR is budget saving among intermediate- and high-risk patients at 5 years. TAVR vs. SAVR for low surgical risk reaches budget neutrality at 5 years. TAVR is associated with higher costs for PPI and budget savings for MDS, AF, and SSI. TAVR also results in savings for non-device costs due to fewer human resource uses and shorter procedure durations. Similarly, TAVR is associated with cost savings due to shorter hospital intensive care unit (ICU) and non-ICU stays. The OWSA consistently revealed that SAVR non-device theater costs were the leading cost driver across all surgical risk levels.

LIMITATIONS

This is the first budget impact analysis of its kind in Saudi Arabia and future research is needed on costing TAVR and SAVR procedures, the economic impact of SSI, and corroborating estimates for the public and private sectors.

CONCLUSIONS

Payers, providers, and policymakers increasingly turn to results of BIA to inform technologies affordability decisions. TAVR with SAPIEN 3 appears to generate savings vs. SAVR from a budget impact perspective across various surgical risk levels in Saudi Arabia.

Modeling the Impact of Delaying TAVR for the Treatment of Aortic Stenosis in the Era of COVID-19

Objective

The aim of this study was to model the short term and 2-year overall survival for intermediate- and low-risk patients with severe symptomatic AS undergoing timely or delayed transcatheter aortic valve replacement during the 2019 novel coronavirus pandemic.

Methods

We developed a decision analysis model to evaluate two treatment strategies for both low-risk and intermediate-risk patients with aortic stenosis during the 2019 novel coronavirus pandemic.

Results

Prompt transcatheter aortic valve replacement resulted in improved 2-year overall survival when compared to delayed intervention for intermediate-risk patients (0.81 versus 0.67) and low-risk patients (0.95 vs 0.85), due to the risk of death or the need for urgent/emergent transcatheter aortic valve replacement in the waiting period. However, if the probability of acquiring the 2019 novel coronavirus is greater than 55% (intermediate risk patients) or 47% (low risk patients), delayed transcatheter aortic valve replacement is favorable to prompt intervention (0.66 vs 0.67, intermediate risk; 0.84 vs 0.85, low risk).

Conclusions and Relevance

Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe aortic stenosis results in improved 2-year survival when local healthcare system resources are not significantly constrained by the 2019 novel coronavirus.

Use of Pre- and Intensified Postprocedural Physiotherapy in Patients with Symptomatic Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement Study (the 4P-TAVR Study)

Background

Physiotherapy prior to open-heart surgery lowers the rate of pneumonia and length of the hospital stay. Pneumonia is a major contributor to short-term mortality following transcatheter aortic valve replacement (TAVR). Hence, we hypothesized that pre- and intensified postprocedural physiotherapy in patients undergoing TAVR might impact the net functional and clinical outcome.

Methods and Results

The 4P-TAVR study was a prospective, monocentric, randomized trial. The study was designed to compare the efficacy and safety of intensified periprocedural physiotherapy including inspiratory muscle training versus standard postprocedural physiotherapy. Patients were randomized in a 1 : 1 fashion. 108 patients were included and followed up for 90 days after TAVR. While patients in group A (control group: 50 patients, age: 81.7 ± 5.0 years, 52% male) did not receive physiotherapy prior to TAVR, group B (intervention group: 58 patients, age: 82.2 ± 5.82 years, 47% male) participated in intensive physiotherapy. Compared to the control group, patients in the interventional group showed a lower incidence of postinterventional pneumonia (10 [20.0%] vs. 3 [5.1%], p=0.016) and had a 3-day shorter mean hospital stay (13.5 ± 6.1 days vs. 10.1 ± 4.7 days, p=0.02). The primary composite endpoint of mortality and rehospitalization was not different between the groups.

Conclusion

Intensified physiotherapy is safe and has positive effects on clinical outcomes up to 90 days after TAVR but has no impact on the primary combined endpoint of mortality and rehospitalization. Longer follow-up, a multicenter design, and a higher number of subjects are needed to confirm these preliminary results. This trial is registered with DRKS00017239.

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Importance

With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined.

Objective

To assess the association between hospital TAVR volume and 30-day readmission.

Design, Setting, and Participants

In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016.

Exposure

Transcatheter aortic valve replacement.

Main Outcomes and Measures

Thirty-day readmissions.

Results

Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and $13 886 [18 333] vs $14 135 [17 939] vs $13 432 [15 725]; P = .63, respectively).

Conclusions and Relevance

We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Infections after transcatheter versus surgical aortic valve replacement: mid-term results of 200 consecutive patients

Background

Transcatheter aortic valve implantation (TAVI) is the standard therapy for high-risk patients with aortic stenosis (AS). TAVI-outcomes are widely investigated in comparison to surgical aortic valve replacement (SAVR), but less is known about infectious complications after TAVI. We aimed to compare early and mid-term infectious outcomes of patients undergoing TAVI or SAVR.

Methods

The present study is a prospective single-centre study including 200 consecutive patients between 06/2014-03/2015 undergoing TAVI (either transfemoral or transapical and transaortic, n=47+53=100) or SAVR (either isolated or concomitant with CABG, n=52+48=100). The mean age and log. EuroSCORE were significantly different between both groups (81±6 versus 69±11 years, P<0.001 and 23.1%±13.8% versus 8.7%±9.5%, P<0.001). Primary endpoints included wound healing disorders, respiratory and urinary tract infections and incidence of endocarditis or sepsis within hospital stay. Secondary endpoints included infectious parameters, infectious related rehospitalisation and 2-year mortality.

Results

Primary endpoints showed no difference in overall TAVI- versus SAVR-groups regarding respiratory- (14% versus 19%, P=0.45), urinary-tract (7% versus 4%, P=0.54) infections, sepsis (5% versus 6%, P=1.0), endocarditis (0% versus 1%, P=1.0) or 30-day mortality (10% versus 4%, P=0.09), except for wound disorders, which were significantly lower in the TAVI-group (1% versus 8%, P=0.035), respectively. Secondary endpoints reported no difference regarding infectious related rehospitalisation (4% versus 4%, P=1.0), but significantly higher 2-year mortality (28% versus 16%, P=0.048) in the TAVI-group.

Conclusions

So far, little has been studied about infectious complications after TAVI. This study reports no difference between the overall TAVI and SAVR groups regarding infectious complications. However, SAVR group show more wound healing disorders but less mortality than TAVI group.

Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States: Insights From the Nationwide Readmissions Database

BACKGROUND

Readmissions after cardiac procedures are common and contribute to increased healthcare utilization and costs. Data on 30-day readmissions after transcatheter aortic valve replacement (TAVR) are limited.

METHODS AND RESULTS

Patients undergoing TAVR (International Classification of Diseases-Ninth Revision-CM codes 35.05 and 35.06) between January and November 2013 who survived the index hospitalization were identified in the Nationwide Readmissions Database. Incidence, predictors, causes, and costs of 30-day readmissions were analyzed. Of 12 221 TAVR patients, 2188 (17.9%) were readmitted within 30 days. Length of stay >5 days during index hospitalization (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.24-1.73), acute kidney injury (HR, 1.23; 95% CI, 1.05-1.44), >4 Elixhauser comorbidities (HR, 1.22; 95% CI, 1.03-1.46), transapical TAVR (HR, 1.21; 95% CI, 1.05-1.39), chronic kidney disease (HR, 1.20; 95% CI, 1.04-1.39), chronic lung disease (HR, 1.16; 95% CI, 1.01-1.34), and discharge to skilled nursing facility (HR, 1.16; 95% CI, 1.01-1.34) were independent predictors of 30-day readmission. Readmissions were because of noncardiac causes in 61.8% of cases and because of cardiac causes in 38.2% of cases. Respiratory (14.7%), infections (12.8%), bleeding (7.6%), and peripheral vascular disease (4.3%) were the most common noncardiac causes, whereas heart failure (22.5%) and arrhythmias (6.6%) were the most common cardiac causes of readmission. Median length of stay and cost of readmissions were 4 days (interquartile range, 2-7 days) and $8302 (interquartile range, $5229-16 021), respectively.

CONCLUSIONS

Thirty-day readmissions after TAVR are frequent and are related to baseline comorbidities, TAVR access site, and post-procedure complications. Awareness of these predictors can help identify and target high-risk patients for interventions to reduce readmissions and costs.