1
|
Cabrucci F, Baudo M, Yamashita Y, Dokollari A, Sicouri S, Ramlawi B. Short and Long-Term Outcomes of Transcatheter Aortic Valve Implantation in the Small Aortic Annulus: A Systematic Literature Review. J Pers Med 2024; 14:937. [PMID: 39338191 PMCID: PMC11433187 DOI: 10.3390/jpm14090937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/28/2024] [Accepted: 08/31/2024] [Indexed: 09/30/2024] Open
Abstract
Transcatheter aortic valve implantation has revolutionized the treatment of aortic stenosis. The small aortic annulus is one of the most challenging aspects of aortic stenosis treatment and since the beginning, TAVI has shown promising results in this subgroup of patients. This systematic literature review aims to investigate the short and long-term outcomes of TAVI in the small aortic annulus. The literature was meticulously screened for this topic until April 2024 using the PRISMA guidelines. Technical aspects, characteristics of this subgroup of patients, hemodynamic performances, and outcomes are discussed. The importance of device selection has shown up, with insight into the differences between self-expandable and the balloon-expandable valves. Two special populations were also taken into account: outcomes of TAVI in the small aortic annulus with bicuspid aortic valve and extra-small aortic annulus. The last 10 years have been paramount in technological advancements, bringing TAVI to broader use in this population. While several important trials underscored the usefulness of TAVI in the small aortic annulus population, the clinical practice still lacks consensus on the ideal device, and the outcomes are debated. The pivotal role of TAVI in this context needs to be addressed with a patient-tailored approach to optimize patient care.
Collapse
Affiliation(s)
- Francesco Cabrucci
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA 19096, USA
| | - Massimo Baudo
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA 19096, USA
| | - Yoshiyuki Yamashita
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA 19096, USA
- Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, PA 19096, USA
| | - Aleksander Dokollari
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA 19096, USA
- Department of Cardiac Surgery, St. Boniface Hospital, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA 19096, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA 19096, USA
- Department of Cardiac Surgery, Lankenau Heart Institute, Main Line Health, Wynnewood, PA 19096, USA
| |
Collapse
|
2
|
Zaheer A, Qiu F, Manoragavan R, Madan M, Sud M, Mamas MA, Wijeysundera HC. Impact of Neighborhood Social Deprivation on Delays to Access for Transcatheter Aortic Valve Replacement: Wait-Times and Clinical Consequences. J Am Heart Assoc 2024; 13:e032450. [PMID: 38879459 PMCID: PMC11255769 DOI: 10.1161/jaha.123.032450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 05/24/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has become the standard of care for severe aortic stenosis treatment. Exponential growth in demand has led to prolonged wait times and adverse patient outcomes. Social marginalization may contribute to adverse outcomes. Our objective was to examine the association between different measures of neighborhood-level marginalization and patient outcomes while on the TAVR waiting list. A secondary objective was to understand if sex modifies this relationship. METHODS AND RESULTS We conducted a population-based retrospective cohort study of 11 077 patients in Ontario, Canada, referred to TAVR from April 1, 2018, to March 31, 2022. Primary outcomes were death or hospitalization while on the TAVR wait-list. Using cause-specific Cox proportional hazards models, we evaluated the relationship between neighborhood-level measures of dependency, residential instability, material deprivation, and ethnic and racial concentration with primary outcomes as well as the interaction with sex. After multivariable adjustment, we found a significant relationship between individuals living in the most ethnically and racially concentrated areas (quintile 4 and 5) and mortality (hazard ratio [HR], 0.64 [95% CI, 0.47-0.88] and HR, 0.73 [95% CI, 0.53-1.00], respectively). There was no significant association between material deprivation, dependency, or residential instability with mortality. Women in the highest ethnic or racial concentration quintiles (4 and 5) had significantly lower risks for mortality (HR values of 0.52 and 0.56, respectively) compared with quintile 1. CONCLUSIONS Higher neighborhood ethnic or racial concentration was associated with decreased risk for mortality, particular for women on the TAVR waiting list. Further research is needed to understand the drivers of this relationship.
Collapse
Affiliation(s)
- Aida Zaheer
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
| | | | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
| | - Mina Madan
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoTorontoCanada
| | - Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
- ICESTorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoTorontoCanada
| | - Mamas A. Mamas
- Keele Cardiovascular Research GroupKeele UniversityKeeleUK
| | - Harindra C. Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada
- ICESTorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoTorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
| |
Collapse
|
3
|
Miranda RN, Qiu F, Manoragavan R, Austin PC, Naimark DMJ, Fremes SE, Ko DT, Madan M, Mamas MA, Sud MK, Tam D, Wijeysundera HC. Transcatheter Aortic Valve Implantation Wait-Time Management: Derivation and Validation of the Canadian TAVI Triage Tool (CAN3T). J Am Heart Assoc 2024; 13:e033768. [PMID: 38390797 PMCID: PMC10944064 DOI: 10.1161/jaha.123.033768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/26/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has seen indication expansion and thus exponential growth in demand over the past decade. In many jurisdictions, the growing demand has outpaced capacity, increasing wait times and preprocedural adverse events. In this study, we derived prediction models that estimate the risk of adverse events on the waitlist and developed a triage tool to identify patients who should be prioritized for TAVI. METHODS AND RESULTS We included adult patients in Ontario, Canada referred for TAVI and followed up until one of the following events first occurred: death, TAVI procedure, removal from waitlist, or end of the observation period. We used subdistribution hazards models to find significant predictors for each of the following outcomes: (1) all-cause death while on the waitlist; (2) all-cause hospitalization while on the waitlist; (3) receipt of urgent TAVI; and (4) a composite outcome. The median predicted risk at 12 weeks was chosen as a threshold for a maximum acceptable risk while on the waitlist and incorporated in the triage tool to recommend individualized wait times. Of 13 128 patients, 586 died while on the waitlist, and 4343 had at least 1 hospitalization. A total of 6854 TAVIs were completed, of which 1135 were urgent procedures. We were able to create parsimonious models for each outcome that included clinically relevant predictors. CONCLUSIONS The Canadian TAVI Triage Tool (CAN3T) is a triage tool to assist clinicians in the prioritization of patients who should have timely access to TAVI. We anticipate that the CAN3T will be a valuable tool as it may improve equity in access to care, reduce preventable adverse events, and improve system efficiency.
Collapse
Affiliation(s)
- Rafael N. Miranda
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
| | | | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
| | - Peter C. Austin
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | - David M. J. Naimark
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Stephen E. Fremes
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Dennis T. Ko
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Mina Madan
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, School of MedicineKeele UniversityStoke‐on‐TrentUnited Kingdom
| | - Maneesh K. Sud
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| | - Derrick Tam
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
| | - Harindra C. Wijeysundera
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoCanada
- Temerty Faculty of MedicineUniversity of TorontoCanada
| |
Collapse
|
4
|
Wijeysundera HC, Gaudino M, Qiu F, Olson MA, Mao J, Manoragavan R, Rong L, Tam DY, Austin PC, Fremes SE, Sedrakyan A. Regional Differences in Outcomes for Patients Undergoing Transcatheter Aortic Valve Replacement in New York State and Ontario. Can J Cardiol 2023; 39:570-577. [PMID: 36737001 PMCID: PMC11116973 DOI: 10.1016/j.cjca.2023.01.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR among jurisdictions. It is unknown if such variation is associated with differences in postprocedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high vs low access of care to TAVR translate to differences in postprocedural outcomes. METHODS In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1, 2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all-cause readmissions. Using indirect standardization, we calculated the observed vs expected outcomes for New York patients, had they been treated in Ontario. RESULTS Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5% of New York patients. With adjustment, this translated to an observed-expected ratio of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients. CONCLUSIONS Having greater access to TAVR may be associated with improved outcomes, potentially because of intervention earlier in the trajectory of the disease.
Collapse
Affiliation(s)
- Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Molly A Olson
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Jialin Mao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Derrick Y Tam
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| |
Collapse
|
5
|
Relationship of Neighbourhood Social Deprivation and Ethnicity on Access to Transcatheter and Surgical Aortic Valve Replacement: A Population-Level Study. Can J Cardiol 2023; 39:22-31. [PMID: 36228886 DOI: 10.1016/j.cjca.2022.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/19/2022] [Accepted: 10/03/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Wide geographic variation in access to transcatheter (TAVR) and surgical (SAVR) aortic valve replacement exists, but the impact of socioethnic factors on the geographic variation of AS management in Ontario, Canada, is unknown. METHODS Neighbourhood rates of AS admissions, as a proxy for AS burden, and downstream TAVR and SAVR referrals and procedures were estimated for the 76 subregions in Ontario. To determine if the socioethnic geographic variations in referrals and procedures were concordant or discordant with AS burden, we calculated Pearson correlation coefficients to determine the relationship between AS burden and each of TAVR referrals, TAVR procedures, SAVR referrals, or SAVR procedures. We developed generalised linear models to determine the association between social deprivation indices captured in the Ontario Marginalization index and the rates of AS burden as well as TAVR/SAVR referral and procedures. RESULTS There was wide geographic variation that was concordant between AS burden and the referral and procedure rates for TAVR and SAVR (correlation coefficients 0.86-0.96). Increased dependency was associated with higher rates of both TAVR/SAVR referrals and procedures (rate ratios 1.63-2.22). Neighbourhoods with a higher concentration of ethnic minorities were associated with lower AS burden as well as lower rates of both SAVR and TAVR referrals and procedures (rate ratios 0.57-0.85). CONCLUSIONS An important ethnic gradient exists in AS burden and in both referral and completion of TAVR and SAVR in Ontario. Further research is necessary to understand if this gradient is appropriate or requires mitigation.
Collapse
|
6
|
Patel RV, Ravindran M, Qiu F, Manoragavan R, Sud M, Tam DY, Madan M, Marcus G, Elbaz‐Greener G, Mamas MA, Wijeysundera HC. Social Deprivation and Post-TAVR Outcomes in Ontario, Canada: A Population-Based Study. J Am Heart Assoc 2022; 12:e028144. [PMID: 36565194 PMCID: PMC9973610 DOI: 10.1161/jaha.122.028144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Transcatheter aortic valve replacement (TAVR)/intervention has become the standard of care for treatment of severe aortic stenosis across the spectrum of risk. There are socioeconomic disparities in access to TAVR. The impact of these disparities on postprocedural outcomes remains unknown. Our objective was to examine the association between neighborhood-level social deprivation and post-TAVR mortality and hospital readmission. Methods and Results We conducted a population-based retrospective cohort study of all 4145 patients in Ontario, Canada, who received TAVR from April 1, 2017, to March 31, 2020. Our co-primary outcomes were 1-year postprocedure mortality and 1-year postprocedure readmission. Using Cox proportional hazards models for mortality and cause-specific competing risk hazard models for readmission, we evaluated the relationship between neighborhood-level measures of residential instability, material deprivation, and concentration of racial and ethnic groups with post-TAVR outcomes. After multivariable adjustment, we found a statistically significant relationship between residential instability and postprocedural 1-year mortality, ranging from a hazard ratio of 1.64 to a hazard ratio of 2.05. There was a significant association between the highest degree of residential instability and 1-year readmission (hazard ratio, 1.23 [95% CI, 1.01-1.49]). There was no association between material deprivation and concentration of racial and ethnic groups with post-TAVR outcomes. Conclusions Residential instability was associated with increased risk for post-TAVR mortality, and the highest quintile of residential instability was associated with increased post-TAVR readmission. To reduce health disparities and promote an equitable health care system, further research and policy interventions will be required to identify and support economically and socially minoritized patients undergoing TAVR.
Collapse
Affiliation(s)
- Raumil V. Patel
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada
| | | | - Feng Qiu
- Institute for Clinical Evaluative SciencesOntarioTorontoCanada
| | - Ragavie Manoragavan
- Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Maneesh Sud
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada,Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Derrick Y. Tam
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada,Division of Cardiac Surgery, Department of SurgerySchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Mina Madan
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | - Gil Marcus
- Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada
| | | | - Mamas A. Mamas
- Keele Cardiovascular Research GroupKeele UniversityKeeleUnited Kingdom
| | - Harindra C. Wijeysundera
- Temerty Faculty of MedicineUniversity of TorontoOntarioTorontoCanada,Institute for Health Policy, Management, and EvaluationOntarioTorontoCanada,Institute for Clinical Evaluative SciencesOntarioTorontoCanada,Division of Cardiology, Department of MedicineSchulich Heart Program, Sunnybrook Health Sciences CentreOntarioTorontoCanada,Sunnybrook Research InstituteOntarioTorontoCanada
| |
Collapse
|
7
|
Early and midterm outcomes of transcatheter aortic-valve replacement with balloon-expandable versus self-expanding valves: A meta-analysis. J Cardiol 2022; 80:204-210. [DOI: 10.1016/j.jjcc.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/19/2022]
|
8
|
Miranda RN, Qiu F, Manoragavan R, Fremes S, Lauck S, Sun L, Tarola C, Tam DY, Mamas M, Wijeysundera HC. Drivers and outcomes of variation in surgical versus transcatheter aortic valve replacement in Ontario, Canada: a population-based study. Open Heart 2022; 9:openhrt-2021-001881. [PMID: 35101899 PMCID: PMC8804707 DOI: 10.1136/openhrt-2021-001881] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/09/2022] [Indexed: 12/21/2022] Open
Abstract
Objectives To understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes. Background Adoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR. Methods We conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions. Results Annual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations. Conclusions Despite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.
Collapse
Affiliation(s)
- Rafael N Miranda
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stephen Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra Lauck
- Centre for Heart Valve Innovation, Saint Paul's Hospital, Vancouver, British Columbia, Canada
| | - Louise Sun
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher Tarola
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mamas Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Keele, UK
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Wang T, Ou A, Xia P, Tian J, Wang H, Cheng Z. Predictors for the risk of permanent pacemaker implantation after transcatheter aortic valve replacement: A systematic review and meta-analysis. J Card Surg 2021; 37:377-405. [PMID: 34775652 DOI: 10.1111/jocs.16129] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/22/2021] [Accepted: 09/26/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is a less invasive treatment than surgery for severe aortic stenosis. However, its use is restricted by the fact that many patients eventually require permanent pacemaker implantation (PPMI). This meta-analysis was performed to identify predictors of post-TAVR PPMI. METHODS The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Relevant studies that met the inclusion criteria were included in the pooling analysis after quality assessment. RESULTS After pooling 67 studies on post-TAVR PPMI risk in 97,294 patients, balloon-expandable valve use was negatively correlated with PPMI risk compared with self-expandable valve (SEV) use (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.37-0.53). Meta-regression analysis revealed that history of coronary artery bypass grafting and higher Society of Thoracic Surgeons (STS) risk score increased the risk of PPMI with SEV utilization. Patients with pre-existing cardiac conduction abnormalities in 28 pooled studies also had a higher risk of PPMI (OR: 2.33, 95% CI: 1.90-2.86). Right bundle branch block (OR: 5.2, 95% CI: 4.37-6.18) and first-degree atrioventricular block (OR: 1.97, 95% CI: 1.38-2.79) also increased PPMI risk. Although the trans-femoral approach was positively correlated with PPMI risk, the trans-apical pathway showed no statistical difference to the trans-femoral pathway. The approach did not increase PPMI risk in patients with STS scores >8. Patient-prosthesis mismatch did not influence post-TAVR PPMI risk (OR: 0.88, 95% CI: 0.67-1.16). We also analyzed implantation depth and found no difference between patients with PPMI after TAVR and those without. CONCLUSIONS SEV selection, pre-existing cardiac conduction abnormality, and trans-femoral pathway selection are positively correlated with PPMI after TAVR. Pre-existing left bundle branch block, patient-prosthesis mismatch, and implantation depth did not affect the risk of PPMI after TAVR.
Collapse
Affiliation(s)
- Tongyu Wang
- Department of Cardiovascular Medicine, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Aixin Ou
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ping Xia
- Department of Cardiovascular Medicine, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jiahu Tian
- Department of Cardiovascular Medicine, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Hongchang Wang
- Department of Emergency Medicine, The First Affiliated Hospital of Lanzhou Medical University, Lanzhou, China
| | - Zeyi Cheng
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
10
|
The Impact of the COVID-19 Pandemic on Cardiac Procedure Wait List Mortality in Ontario, Canada. Can J Cardiol 2021; 37:1547-1554. [PMID: 34600793 PMCID: PMC8481095 DOI: 10.1016/j.cjca.2021.05.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/02/2021] [Accepted: 05/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background The novel SARS-CoV-2 (COVID-19) pandemic has dramatically altered the delivery of healthcare services, resulting in significant referral pattern changes, delayed presentations, and procedural delays. Our objective was to determine the effect of the COVID-19 pandemic on all-cause mortality in patients awaiting commonly performed cardiac procedures. Methods Clinical and administrative data sets were linked to identify all adults referred for: (1) percutaneous coronary intervention; (2) coronary artery bypass grafting; (3) valve surgery; and (4) transcatheter aortic valve implantation, from January 2014 to September 2020 in Ontario, Canada. Piece-wise regression models were used to determine the effect of the COVID-19 pandemic on referrals and procedural volume. Multivariable Cox proportional hazards models were used to determine the effect of the pandemic on waitlist mortality for the 4 procedures. Results We included 584,341 patients who were first-time referrals for 1 of the 4 procedures, of whom 37,718 (6.4%) were referred during the pandemic. The pandemic period was associated with a significant decline in the number of referrals and procedures completed compared with the prepandemic period. Referral during the pandemic period was a significant predictor for increased all-cause mortality for the percutaneous coronary intervention (hazard ratio, 1.83; 95% confidence interval, 1.47-2.27) and coronary artery bypass grafting (hazard ratio, 1.96; 95% confidence interval, 1.28-3.01), but not for surgical valve or transcatheter aortic valve implantation referrals. Procedural wait times were shorter during the pandemic period compared with the prepandemic period. Conclusions There was a significant decrease in referrals and procedures completed for cardiac procedures during the pandemic period. Referral during the pandemic was associated with increased all-cause mortality while awaiting coronary revascularization.
Collapse
|
11
|
Marcus G, Qiu F, Manoragavan R, Ko DT, Elbaz-Greener G, Chung JCY, Sud M, Farkouh ME, Madan M, Fremes SE, Wijeysundera HC. Temporal Trends and Drivers of Heart Team Utilization in Transcatheter Aortic Valve Replacement: A Population-Based Study in Ontario, Canada. J Am Heart Assoc 2021; 10:e020741. [PMID: 34155897 PMCID: PMC8403321 DOI: 10.1161/jaha.120.020741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The multidisciplinary Heart Team (HT) is recommended for management decisions for transcatheter aortic valve replacement (TAVR) candidates, and during TAVR procedures. Empiric evidence to support these recommendations is limited. We aimed to explore temporal trends, drivers, and outcomes associated with HT utilization. Methods and Results TAVR candidates were identified in Ontario, Canada, from April 1, 2012 to March 31, 2019. The HT was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period. The procedural team was defined as a billing code during the TAVR procedure. Hierarchical logistical models were used to determine the drivers of HT. Median odds ratios were calculated to quantify the degree of variation among hospitals. Of 10 412 patients referred for TAVR consideration, 5489 (52.7%) patients underwent a HT during the referral period, with substantial range between hospitals (median odds ratio of 1.78). Utilization of a HT for TAVR referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVR program size, were found associated with lower HT utilization. In TAVR procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals. Conclusions There has been substantial decline in HT utilization for TAVR candidates over time. In addition, maturity of TAVR programs was associated with lower HT utilization.
Collapse
Affiliation(s)
- Gil Marcus
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | | | - Ragavie Manoragavan
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Dennis T Ko
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Gabby Elbaz-Greener
- Department of Cardiology Hadassah Medical Center Jerusalem Israel.,Faculty of Medicine Hebrew University of Jerusalem Israel
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery Department of Surgery Peter Munk Cardiac Centre University Health NetworkUniversity of Toronto Ontario Canada
| | - Maneesh Sud
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre University of Toronto Canada
| | - Mina Madan
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Stephen E Fremes
- Schulich Heart Program Division of Cardiac Surgery Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| |
Collapse
|
12
|
Sunner M, Qiu F, Manoragavan R, Roifman I, Tam DY, Fremes SC, Sun L, Rahal M, Woodward G, Austin PC, Wijeysundera HC. Predictors of cumulative cost for patients with severe aortic stenosis referred for surgical or transcatheter aortic valve replacement: a population-based study in Ontario, Canada. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:265-272. [PMID: 33351143 DOI: 10.1093/ehjqcco/qcaa094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/29/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022]
Abstract
AIMS Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has transformed severe aortic stenosis (AS) management. Our aim was understand AS cost drivers from referral to 1-year post-procedure. METHODS AND RESULTS We identified patients referred for either TAVR/SAVR between 1 April 2015 and 31 March 2018, with follow-up until 31 March 2019 in Ontario, Canada. We stratified costs into (i) a referral phase, (ii) a procedural phase from the procedure date to 60 days post-procedure, and (iii) post-procedure phase from 61 days to 1 year. Multivariable regression modelling using generalized linear models with a log link gamma distribution was used to identify cost drivers in each phase. The study cohort included 12 086 AS patients; 4832 were referred for TAVR and 7254 were referred for SAVR. The median cost for TAVR was higher than SAVR in the referral ($3593 vs. $2944) and post-procedural ($5938 vs. $3257) phases. In contrast, for the procedural phase, SAVR had a median cost of $29 756 vs. $27 907 for TAVR. Predictors of high cost in the referral phase were longer wait-time, and an urgent in-hospital procedure. In the procedural phase, procedural complications were the major drivers of higher cost. In the post-procedural phase, patient co-morbidities were the major drivers, specifically dialysis, liver disease, cancer, peripheral vascular disease, and diabetes mellitus. CONCLUSION We identified distinct patterns of cost accumulation and modifiable drivers for SAVR compared with TAVR; these drivers may guide clinical and health policy decisions to make AS care more efficient.
Collapse
Affiliation(s)
- Manjot Sunner
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada
| | | | - Ragavie Manoragavan
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada
| | - Idan Roifman
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Louise Sun
- ICES, Toronto, Ontario, Canada.,Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Peter C Austin
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Room A202, Toronto, Ontario M4N 3M5, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Ravindran M, Henning KA, Qiu F, Manoragavan R, Dvir D, Shuvy M, Sud MK, Wijeysundera HC. Predictors of Long-term Cardiovascular Versus Non-cardiovascular Mortality and Repeat Intervention in Patients Having Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 135:105-112. [PMID: 32866442 DOI: 10.1016/j.amjcard.2020.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 11/26/2022]
Abstract
There is a paucity of literature characterizing the risk of long-term mortality and reintervention after transcatheter aortic valve implantation (TAVI). Addressing this gap has become increasingly relevant with the inclusion of intermediate and low surgical risk patients and the need for data to inform their long-term management. We sought to investigate the long-term trends and predictors of cardiovascular versus noncardiovascular mortality as well as reintervention in post-TAVI patients. Our cohort consisted of 5,406 patients who underwent TAVI in Ontario, Canada from 2011 to 2018. We used Kaplan-Meier analysis to estimate 7-year all-cause mortality and a Cox proportional hazard model to identify demographic, co-morbid, and procedural predictors. Similarly, cumulative incidence functions were used to estimate cardiovascular versus noncardiovascular mortality at 5 years, with predictors identified through Fine-Gray models. The Kaplan-Meier estimate for 7-year all-cause mortality in our cohort was 67%; this was driven by a number of co-morbidities including congestive heart failure and liver disease. We found that cardiovascular death was more likely for approximately the first 2 years post-TAVI whereas noncardiovascular death was more likely from this point to the end of the study. We identified a number of factors that uniquely modified the risk of either cardiovascular or noncardiovascular mortality. Only 1.6% of patients who underwent repeat intervention. The distinct factors associated with cardiovascular versus noncardiovascular death suggest different approaches to short-term and long-term surveillance of patients post-TAVI by both the heart team and primary care providers.
Collapse
|
14
|
Albassam O, Henning KA, Qiu F, Cram P, Sheth TN, Ko DT, Woodward G, Austin PC, Wijeysundera HC. Increasing Wait-Time Mortality for Severe Aortic Stenosis: A Population-Level Study of the Transition in Practice From Surgical Aortic Valve Replacement to Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2020; 13:e009297. [PMID: 33167700 DOI: 10.1161/circinterventions.120.009297] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has emerged as a reasonable alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis (AS). There is limited data on temporal trends in wait-times and access to care for patients with AS, irrespective of treatment modality. We sought to investigate the trends in wait-times for the treatment (either SAVR or TAVR) of AS in Ontario, Canada, and to understand the drivers of wait-list mortality and hospitalization due to heart failure. METHODS In this population-level retrospective cohort study, we identified patients from April 1, 2012, to March 31, 2018, who were referred for treatment of symptomatic severe AS awaiting either SAVR or TAVR. The primary outcome was the median total wait-time from referral date to either SAVR or TAVR procedure. Primary clinical outcomes were all-cause mortality and heart failure-related hospitalizations while on the wait-list. RESULTS The referral cohort consisted of a total of 22 876 referrals for aortic valve replacement, with (N=8098) TAVR and (N=14 778) SAVR referrals. The mean and median wait times for the overall AVR cohort were 87 and 59 days, respectively. The TAVR subcohort had longer wait-times (median 84 days) compared with the SAVR subcohort (median 50 days). Year over year, there was a statistically significant an increase in wait-times (P<0.001) for the overall AS cohort as well as each of the TAVR (P<0.0001) and SAVR (P<0.0001) subgroups. Wait-time mortality was 2.5% (TAVR 5.2% and SAVR 1.05%), while the cumulative probability of heart failure hospitalization was 3.6% (TAVR 7.7% and SAVR 1.3%). CONCLUSIONS In patients with severe symptomatic AS awaiting aortic valve replacement, there has been a trend of increasing wait times for both SAVR and TAVR. This was associated with increasing mortality and hospitalizations related to heart failure while on the wait-list.
Collapse
Affiliation(s)
- Omar Albassam
- Schulich Heart Program, Sunnybrook Health Sciences Center (O.A., D.T.K., H.C.W.), University of Toronto, Canada
| | - Kayley A Henning
- ICES, Toronto, ON, Canada (K.A.H., F.Q., P.C., D.T.K., P.C.A., H.C.W.)
| | - Feng Qiu
- ICES, Toronto, ON, Canada (K.A.H., F.Q., P.C., D.T.K., P.C.A., H.C.W.)
| | - Peter Cram
- Department of Medicine (P.C., D.T.K., H.C.W.), University of Toronto, Canada
- ICES, Toronto, ON, Canada (K.A.H., F.Q., P.C., D.T.K., P.C.A., H.C.W.)
- Division of General Medicine, and Geriatrics, Sinai Health System and University Health Network, Toronto, ON, Canada (P.C.)
| | - Tej N Sheth
- Hamilton Health Sciences and Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (T.N.S.)
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Center (O.A., D.T.K., H.C.W.), University of Toronto, Canada
- Department of Medicine (P.C., D.T.K., H.C.W.), University of Toronto, Canada
- Institute for Health Policy Management and Evaluation (D.T.K., H.C.W.), University of Toronto, Canada
- ICES, Toronto, ON, Canada (K.A.H., F.Q., P.C., D.T.K., P.C.A., H.C.W.)
| | | | - Peter C Austin
- ICES, Toronto, ON, Canada (K.A.H., F.Q., P.C., D.T.K., P.C.A., H.C.W.)
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Center (O.A., D.T.K., H.C.W.), University of Toronto, Canada
- Department of Medicine (P.C., D.T.K., H.C.W.), University of Toronto, Canada
- Institute for Health Policy Management and Evaluation (D.T.K., H.C.W.), University of Toronto, Canada
- ICES, Toronto, ON, Canada (K.A.H., F.Q., P.C., D.T.K., P.C.A., H.C.W.)
| |
Collapse
|
15
|
Czarnecki A, Qiu F, Henning KA, Fang J, Jennett M, Austin PC, Ko DT, Radhakrishnan S, Wijeysundera HC. Comparison of 1-Year Pre- and Post-Transcatheter Aortic Valve Replacement Hospitalization Rates: A Population-Based Cohort Study. Can J Cardiol 2020; 36:1616-1623. [DOI: 10.1016/j.cjca.2020.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/19/2019] [Accepted: 01/08/2020] [Indexed: 11/24/2022] Open
|
16
|
Predictors of Cumulative Health Care Costs Associated With Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis. Can J Cardiol 2020; 36:1244-1251. [DOI: 10.1016/j.cjca.2019.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/04/2019] [Accepted: 12/08/2019] [Indexed: 11/23/2022] Open
|
17
|
Tham JLM, Adams H, Paleri S, Wright C, Dimitriou J, Newcomb A, MacIsaac AI, Whitbourn RJ, Palmer SC. Clinical outcomes of self-expandable vs. balloon-expandable TAVI for severe aortic stenosis. Acta Cardiol 2020; 75:218-225. [PMID: 30931804 DOI: 10.1080/00015385.2019.1572959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Transcatheter aortic valve implantation (TAVI) is an established therapy for patients with severe aortic stenosis (AS). There is limited data exploring differences in outcomes post-TAVI SEV vs. BEV. This study compared procedural success and 30-d clinical outcomes self-expandable valves (SEV), vs. balloon-expandable valves (BEV) for patients with severe AS.Methods: Retrospective analysis was undertaken of patients receiving TAVI at St Vincent's Hospital, Melbourne between August 2009 and May 2018. The primary endpoints included procedural success, clinical outcomes and complication rates at 30-d.Results: Out of 151 patients undergoing TAVI, 70 received (46.3%) SEV (Medtronic CoreValve & Evolut-R) and 81 (53.6%) BEV (Edwards SAPIEN-XT & S3). The mean Society of Thoracic Surgery (STS) risk score did not differ between the groups, SEV (83.6 ± 4.9 years, STS 4.4 ± 3.8) compared to BEV (82.3 ± 5.8 years, STS 4.9 ± 4.9). Procedural success was similar SEV 67 (95.7%) vs. BEV 78 (96.3%). Rates of ≥ moderate paravalvular aortic regurgitation (PAR) at 30-d were significantly higher in SEV compared to BEV (6.7 vs. 0.0%; p = .02). SEV patients had higher rates of pacemaker insertion (36.4 vs. 9.5%; p = .001) and stroke rates (12.4 vs. 1.4%; p = .04) compared to BEV patients. The difference in 30-d mortality between the two groups was similar (SEV 4.6% vs. BEV 1.3%; p = .23).Conclusions: This real-world retrospective analysis demonstrates higher rates of ≥ moderate PAR, stroke and pacemaker insertion with SEV compared to BEV at 30 d post-TAVI for severe symptomatic AS.
Collapse
Affiliation(s)
| | - Heath Adams
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Sarang Paleri
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Christine Wright
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Jim Dimitriou
- Department of Cardiac Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Andrew Newcomb
- Department of Cardiac Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Andrew I. MacIsaac
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Robert J. Whitbourn
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Sonny C. Palmer
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| |
Collapse
|
18
|
Henning KA, Ravindran M, Qiu F, Fam NP, Seth TN, Austin PC, Wijeysundera HC. Impact of procedural capacity on transcatheter aortic valve replacement wait times and outcomes: a study of regional variation in Ontario, Canada. Open Heart 2020; 7:openhrt-2020-001241. [PMID: 32393658 PMCID: PMC7223466 DOI: 10.1136/openhrt-2020-001241] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/05/2020] [Accepted: 04/21/2020] [Indexed: 01/05/2023] Open
Abstract
Background There has been rapid growth in the demand for transcatheter aortic valve replacement (TAVR), which has the potential to overwhelm current capacity. This imbalance between demand and capacity may lead to prolonged wait times, and subsequent adverse outcomes while patients are on the waitlist. We sought to understand the relationship between regional differences in capacity, TAVR wait times and morbidity/mortality on the waitlist. Methods and results We modelled the effect of TAVR capacity, defined as the number of TAVR procedures per million residents/region, on the hazard of having a TAVR in Ontario from April 2012 to March 2017. Our primary outcome was the time from referral to a TAVR procedure or other off-list reasons on the waitlist/end of the observation period as measured in days. Clinical outcomes of interest were all-cause mortality, all-cause hospitalisations or heart failure-related hospitalisations while on the waitlist for TAVR. There was an almost fourfold difference in TAVR capacity across the 14 regions in Ontario, ranging from 31.5 to 119.5 TAVR procedures per million residents. The relationship between TAVR capacity and wait times was complex and non-linear. In general, increased capacity was associated with shorter wait times (p<0.001), reduced mortality (HR 0.94; p=0.08) and all-cause hospitalisations (p=0.009). Conclusions The results of the present study have important policy implications, suggesting that there is a need to improve TAVR capacity, as well as develop wait-time strategies to triage patients, in order to decrease wait times and mitigate the hazard of adverse patient outcomes while on the waitlist.
Collapse
Affiliation(s)
- Kayley A Henning
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mithunan Ravindran
- Department of Cardiology, Schulich Heart Centre, University of Toronto, Toronto, Ontario, Canada
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Neil P Fam
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tej N Seth
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Department of Cardiology, Schulich Heart Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Analysis of length of stay after transfemoral transcatheter aortic valve replacement: results from the FRANCE TAVI registry. Clin Res Cardiol 2020; 110:40-49. [PMID: 32335689 DOI: 10.1007/s00392-020-01647-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Currently, there are no recommendations regarding the minimum duration of in-hospital monitoring after transfemoral (TF) transcatheter aortic valve replacement (TAVR) and practices are extremely heterogeneous. We, therefore, aimed to evaluate length of stay (LOS) and predictive factors for late discharge after TF TAVR using data from the FRANCE TAVI registry. METHODS TAVR was performed in 12,804 patients in 48 French centers between 2013 and 2015. LOS was evaluated in 5857 TF patients discharged home. LOS was calculated from TAVR procedure (day 0) to discharge. The study population was divided into three groups based on LOS values. Patients discharged within 3 days constituted the "very early" discharge group, patients with a LOS between 3 and 6 days constituted the "early" discharge group, and patients with a length of stay > 6 days constituted the "late" discharge group. RESULTS The median LOS was 7 (5-9) days and was extremely variable among centers. The proportion of patients discharged very early, early, and late was 4.4% (n = 256), 33.7% (n = 1997), and 61.9% (n = 3624) respectively. Variables associated with late discharge were female sex, co-morbidities, major complications, self-expandable valve, general anesthesia, and a significant center effect. In contrast, history of previous pacemaker was a protective factor. The composite of death and re-admission in the very early and early versus late discharge groups was similar at 30 days (3.3% vs. 3.5%, p = 0.66). CONCLUSIONS LOS is extremely variable after TF TAVR in France. Co-morbidities and complications were predictive factors of late discharge after TAVI. Interestingly, the use of self-expandable prosthesis and general anesthesia may also contribute to late discharge. Our results confirm that early discharge is safe.
Collapse
|
20
|
Kumar V, Sandhu GS, Harper CM, Ting HH, Rihal CS. Transcatheter Aortic Valve Replacement Programs: Clinical Outcomes and Developments. J Am Heart Assoc 2020; 9:e015921. [PMID: 32301367 PMCID: PMC7428521 DOI: 10.1161/jaha.120.015921] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transcatheter aortic valve replacement is a relatively recent revolutionary treatment that has now become a standard procedure for treating severe aortic stenosis. In this article, the authors review the clinical history of transcatheter aortic valve replacement, summarize the major clinical trials, and describe the evolution of the technique over time. In doing so, the authors hope to provide a clear and concise review of the history and clinical evidence behind transcatheter aortic valve replacement.
Collapse
Affiliation(s)
| | | | | | - Henry H Ting
- Department of Cardiology Mayo Clinic Rochester MN
| | | |
Collapse
|
21
|
Impact of Coronary Artery Severity and Revascularization Prior to Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 125:924-930. [PMID: 31954508 DOI: 10.1016/j.amjcard.2019.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022]
Abstract
The prevalence of coexisting coronary artery disease (CAD) is high in patients who underwent transcatheter aortic valve implantation (TAVI). Our objective was to first determine if the severity of CAD before TAVI had an important impact on post-TAVI outcomes and second, if revascularization with percutaneous coronary intervention (PCI) before TAVI modified this relation. In this retrospective population-based study in Ontario, Canada, we identified all patients with obstructive CAD who underwent TAVI from April 1, 2012 to March 31, 2017. Our primary outcomes of interest were all-cause mortality within 30-day and 1-year post-TAVI procedure. Secondary outcomes included 30-day and 1-year all-cause readmissions. We developed multivariable Cox proportional hazard models, with a robust sandwich-type variance estimator to account for clustering within TAVI centers. These models included an interaction term between severity of CAD and PCI before TAVI. The study cohort included 888 of whom 444 (50%) patients underwent PCI before TAVI procedure. In the Cox models, we found that severity of CAD before TAVI was not significantly associated with post-TAVI outcomes. The only exception was 1 to 2 vessel/s disease which was a significant predictor of 1-year readmission. Pre-TAVI PCI was not significantly associated with outcomes, nor did it modify the relation between severity of CAD pre-TAVI and outcomes. In conclusion, we did not find a consistent relation between severity of CAD and revascularization with post-TAVI outcomes.
Collapse
|
22
|
Tam DY, Dharma C, Rocha RV, Ouzounian M, Wijeysundera HC, Austin PC, Chikwe J, Gaudino M, Fremes SE. Transcatheter ViV Versus Redo Surgical AVR for the Management of Failed Biological Prosthesis. JACC Cardiovasc Interv 2020; 13:765-774. [DOI: 10.1016/j.jcin.2019.10.030] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/07/2019] [Accepted: 10/15/2019] [Indexed: 11/16/2022]
|
23
|
Lee P, Byrnes J, Mervin M, Scuffham P. Outcomes of transcatheter aortic valve implantation for intermediate-risk patients in Australia: the SOLACE-AU trial. J Med Econ 2019; 22:1298-1306. [PMID: 31491351 DOI: 10.1080/13696998.2019.1663356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Few studies have examined the safety and efficacy of transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in Australian patients. SOLACE-AU was a single-arm, open-label clinical trial conducted in Australian hospitals to determine the safety, performance, and cost implications of TAVI in patients with severe, symptomatic AS at intermediate surgical risk.Methods: This was a prospective, pragmatic, single-arm, multi-center, observational trial of 199 patients with severe, symptomatic AS treated with transfemoral TAVI using the SAPIEN XT transcatheter heart valve (THV) at 11 hospitals in Australia. The primary outcome was Valve Academic Research Consortium-2 (VARC-2) criteria - a composite of seven safety endpoints. Kaplan-Meier (KM) estimates and descriptive analyses were used to evaluate the impact of transfemoral TAVI on safety and valve performance. We also evaluated patient health-related quality of life (QoL) and healthcare resources used throughout the trial.Results: The valve was successfully implanted in 88% of patients. The VARC-2 outcome at 30 days was 12.1% (95% CI: 8.3-17.5%), and almost 90% of patients had improved heart failure symptoms at 1 year based on New York Heart Association functional class criteria. Patient QoL remained stable over time, with mean EQ-5D-3L scores being 0.71 ± 0.20 at baseline and 0.71 ± 0.21 at 2 years. Duration of post-procedure hospitalization (mean: 6.9 ± 4.7 days) decreased as procedural familiarity increased. The median total cost of TAVI decreased 10.1% at 3 years after introduction of the procedure at the sites.Conclusions: The SOLACE-AU trial demonstrated favorable safety and performance of the SAPIEN XT valve in patients with AS at intermediate risk of surgical complications.
Collapse
Affiliation(s)
- Peter Lee
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Josh Byrnes
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Merehau Mervin
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| |
Collapse
|
24
|
Reichenspurner H, Schaefer A, Schäfer U, Tchétché D, Linke A, Spence MS, Søndergaard L, LeBreton H, Schymik G, Abdel-Wahab M, Leipsic J, Walters DL, Worthley S, Kasel M, Windecker S. Self-Expanding Transcatheter Aortic Valve System for Symptomatic High-Risk Patients With Severe Aortic Stenosis. J Am Coll Cardiol 2019; 70:3127-3136. [PMID: 29268926 DOI: 10.1016/j.jacc.2017.10.060] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/15/2017] [Accepted: 10/17/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The CENTERA transcatheter heart valve (THV) is a low-profile, self-expanding nitinol valve made from bovine pericardial tissue that is 14-F compatible with a motorized delivery system allowing for repositionability. OBJECTIVES The pivotal study evaluated safety and efficacy of this THV in high-surgical-risk study patients with severe symptomatic aortic stenosis. METHODS Implantations were completed in 23 centers. Clinical and echocardiographic outcomes were assessed at baseline, discharge, and 30 days. Major events were adjudicated by an independent clinical events committee. Echocardiograms and computed tomography scans were reviewed by core laboratories. The primary endpoint was all-cause mortality at 30 days. RESULTS Between March 25, 2015 and July 5, 2016, 203 patients with severe symptomatic aortic stenosis and increased surgical risk, as determined by the heart team, were treated by transfemoral THV implantation (age 82.7 ± 5.5 years, 67.5% female, 68.0% New York Heart Association functional class III/IV). At 30 days, mortality was 1%, disabling stroke occurred in 2.5% of patients, and New York Heart Association functional class I/II was observed in 93.0% of patients. Effective orifice area increased from 0.71 ± 0.20 cm2 to 1.88 ± 0.43 cm2 (p < 0.001). Mean aortic transvalvular gradient decreased from 40.5 ± 13.2 mm Hg to 7.2 ± 2.8 mm Hg at 30 days post-procedure (p < 0.001). Paravalvular aortic regurgitation at 30 days was moderate or higher in 0.6% of patients. A new permanent pacemaker was implanted in 4.5% of patients receiving the THV (4.9% for patients at risk). CONCLUSIONS The herein described THV is safe and effective at 30 days with low mortality, significant improvements in hemodynamic outcomes, and low incidence of adverse events. Of particular interest is the low incidence of permanent pacemaker implantations. (Safety and Performance Study of the Edwards CENTERA-EU Self-Expanding Transcatheter Heart Valve [CENTERA-2]; NCT02458560).
Collapse
Affiliation(s)
- Hermann Reichenspurner
- Departments of Cardiovascular Surgery and General and Interventional Cardiology, University Heart Center, Hamburg, Germany.
| | - Andreas Schaefer
- Departments of Cardiovascular Surgery and General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Ulrich Schäfer
- Departments of Cardiovascular Surgery and General and Interventional Cardiology, University Heart Center, Hamburg, Germany
| | - Didier Tchétché
- Cardiologie Générale et Interventionelle, Clinique Pasteur, Toulouse, France
| | - Axel Linke
- Department of Internal Medicine/Cardiology, Heart Center and Leipzig Heart Institute, University of Leipzig, Leipzig, Germany
| | - Mark S Spence
- Cardiology Department, Royal Victoria Hospital, Belfast, United Kingdom
| | | | - Hervé LeBreton
- Centre cardio-pneumologique, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
| | - Gerhard Schymik
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | | | - Jonathon Leipsic
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren L Walters
- Department of Cardiology, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Stephen Worthley
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Markus Kasel
- Department of Cardiology, German Heart Center Munich, Munich, Germany
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital (Inselspital), Bern, Switzerland
| |
Collapse
|
25
|
Brennan PF, Spence MS. Self-expanding CENTERA valve for the treatment of severe, symptomatic aortic stenosis. Future Cardiol 2019; 15:79-84. [DOI: 10.2217/fca-2018-0074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is now an established treatment option for both high and intermediate operative risk patients with severe symptomatic aortic stenosis. The number of patients undergoing TAVI has increased over the last decade warranting continued technological improvements in transcatheter heart valve (THV) systems. The novel CENTERA self-expanding THV (Edwards Lifesciences, CA, USA) received CE approval this year. It is deliverable through a 14Fr sheath and has a unique motorized delivery system. The CENTERA-2 study results demonstrated a favorable survival rate at 30 days (99%), as well as a low need for new permanent pacemaker implantation (4.9%). 1-year outcomes reported a low incidence of >moderate paravalvular leak (0.6%) and consistently favorable THV hemodynamics making this a competitive THV for patients with severe aortic stenosis.
Collapse
Affiliation(s)
- Paul F Brennan
- Department of Cardiology, Royal Victoria Hospital, Belfast Health & Social Care Trust, Belfast, Country Antrim, Northern Ireland, BT12 6BA
| | - Mark S Spence
- Department of Cardiology, Royal Victoria Hospital, Belfast Health & Social Care Trust, Belfast, Country Antrim, Northern Ireland, BT12 6BA
| |
Collapse
|
26
|
Czarnecki A, Austin PC, Fremes SE, Tu JV, Wijeysundera HC, Ko DT. Association between transitional care factors and hospital readmission after transcatheter aortic valve replacement: a retrospective observational cohort study. BMC Cardiovasc Disord 2019; 19:23. [PMID: 30658586 PMCID: PMC6339340 DOI: 10.1186/s12872-019-1003-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/14/2019] [Indexed: 01/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Andrew Czarnecki
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada. .,Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada. .,Institute for Clinical Evaluative Sciences, G-106 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.,Institute for Clinical Evaluative Sciences, G-106 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Stephen E Fremes
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada
| | - Jack V Tu
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.,Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.,Institute for Clinical Evaluative Sciences, G-106 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.,Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.,Institute for Clinical Evaluative Sciences, G-106 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Dennis T Ko
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.,Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.,Institute for Clinical Evaluative Sciences, G-106 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| |
Collapse
|
27
|
Elbaz-Greener G, Qiu F, Masih S, Fang J, Austin PC, Cantor WJ, Dvir D, Asgar AW, Webb JG, Ko DT, Wijeysundera HC. Profiling Hospital Performance Based on Mortality After Transcatheter Aortic Valve Replacement in Ontario, Canada. Circ Cardiovasc Qual Outcomes 2018; 11:e004947. [PMID: 30562064 DOI: 10.1161/circoutcomes.118.004947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Public reporting of hospital-level outcomes is increasingly common as a means to target quality improvement strategies to ensure the delivery of optimal care. Despite the rapid dissemination of transcatheter aortic valve replacement (TAVR), there is a paucity of reliable case-mix adjustment models for hospital profiling in TAVR. Our objective was to develop and evaluate different models for calculating risk-standardized all-cause mortality rates (RSMRs) post-TAVR. METHODS AND RESULTS In this population-based study in Ontario, Canada, we identified all patients who underwent a TAVR procedure between April 1, 2012, and March 31, 2016. For each hospital, we calculated 30-day and 1-year RSMR, using 2-level hierarchical logistic regression models that accounted for patient-specific demographic and clinical characteristics, as well as the clustering of patients within the same hospital using a hospital-specific random effects. We classified each hospital into one of 3 groups: performing worse than expected, better than expected, or performing as expected, based on whether the 95% CI of the RSMR was above, below, or included the provincial average mortality rate, respectively. Our cohort consisted of 2129 TAVR procedures performed at 10 hospitals. The observed mortality was 7.0% at 30 days and 16.4% at 1 year, with a range of 4% to 10% and 8% to 22%, respectively, across hospitals. We developed case-mix adjustment models using 28 clinically relevant variables. Using 30-day and 1-year RSMR to profile each hospital, we found that all hospitals performed as expected, with 95% CI that included the provincial average. CONCLUSIONS We found no significant interhospital variation in RSMR among hospitals, suggesting that quality improvement efforts should be directed at aspects other than the variation in observed mortality.
Collapse
Affiliation(s)
- Gabby Elbaz-Greener
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (G.E.-G., D.T.K., H.C.W.).,Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel (G.E.-G.)
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Shannon Masih
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.).,Chronic Disease and Injury Prevention, Public Health, Region of Peel (S.M.)
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Peter C Austin
- Sunnybrook Research Institute, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Health Policy Management and Evaluation, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Warren J Cantor
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.)
| | - Danny Dvir
- Division of Cardiology, University of Washington, Seattle (D.D.)
| | - Anita W Asgar
- Institute for Cardiology, University of Montréal, Quebec, Canada (A.W.A.)
| | - John G Webb
- Center for Heart Valve Innovation, St Paul's Hospital, University of British Columbia, Vancouver (J.G.W.)
| | - Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (G.E.-G., D.T.K., H.C.W.).,Sunnybrook Research Institute, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Health Policy Management and Evaluation, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Harindra C Wijeysundera
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (G.E.-G., D.T.K., H.C.W.).,Sunnybrook Research Institute, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Health Policy Management and Evaluation, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| |
Collapse
|
28
|
Schaefer A, Schirmer J, Schofer N, Schneeberger Y, Deuschl F, Blankenberg S, Reichenspurner H, Conradi L, Schäfer U. Transaxillary transcatheter aortic valve implantation utilizing a novel vascular closure device with resorbable collagen material: a feasibility study. Clin Res Cardiol 2018; 108:779-786. [PMID: 30560381 DOI: 10.1007/s00392-018-1407-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/13/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We herein aimed to evaluate technical feasibility of transaxillary (Tax) transcatheter aortic valve implantation (TAVI) utilizing a novel vascular closure device with a resorbable collagen plug and absence of suture material. METHODS Between 05/2018 and 8/2018, eight patients (76.0 ± 5.9 years, 62.5% male, logEuroSCORE I 23.6 ± 4.7) received Tax-TAVI using the MANTA™ vascular closure device. Implanted transcatheter heart valves consisted of Edwards Sapien 3, NVT Allegra, Medtronic CoreValve EvolutR and SJM Portico. RESULTS Puncture location depth was variable (3.5-7.5 cm). The left subclavian artery was used in five cases, the right subclavian artery in three cases. Low-pressure balloon-angioplasty for vessel closure was performed in 5/8 patients. VARC-2 defined device success was met in all patients. Major access site complication occurred in one patient with aneurysma spurium of the subclavian artery and consecutive stent implantation on postoperative day 5. CONCLUSION The MANTA™ device is applicable in Tax-TAVI, with potential particular advantages regarding easiness of use and marked access for subsequent interventions in case of vascular complications. Before conclusions regarding clinical efficacy and safety can be made, the device has to be evaluated in larger patient cohorts.
Collapse
Affiliation(s)
- Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Johannes Schirmer
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Niklas Schofer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Yvonne Schneeberger
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Florian Deuschl
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ulrich Schäfer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| |
Collapse
|
29
|
Tam DY, Fang J, Tran A, Tu JV, Ko DT, Deb S, Fremes SE. A Clinical Risk Scoring Tool to Predict Readmission After Cardiac Surgery: An Ontario Administrative and Clinical Population Database Study. Can J Cardiol 2018; 34:1655-1664. [DOI: 10.1016/j.cjca.2018.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022] Open
|
30
|
Tam DY, Hughes A, Wijeysundera HC, Fremes SE. Cost-Effectiveness of Self-Expandable Transcatheter Aortic Valves in Intermediate-Risk Patients. Ann Thorac Surg 2018; 106:676-683. [DOI: 10.1016/j.athoracsur.2018.03.069] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/09/2018] [Accepted: 03/26/2018] [Indexed: 11/27/2022]
|
31
|
Aljabbary T, Qiu F, Masih S, Fang J, Elbaz-Greener G, Austin PC, Rodés-Cabau J, Ko DT, Singh S, Wijeysundera HC. Association of Clinical and Economic Outcomes With Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement. JAMA Netw Open 2018; 1:e180088. [PMID: 30646053 PMCID: PMC6324315 DOI: 10.1001/jamanetworkopen.2018.0088] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE The literature is inconsistent regarding the impact of permanent pacemaker implantation after transcatheter aortic valve replacement. OBJECTIVE To evaluate clinical and economic outcomes in patients who required permanent pacemaker implantation during the index hospitalization after transcatheter aortic valve replacement. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study using data from a multicenter registry included patients who underwent a transcatheter aortic valve replacement procedure from April 1, 2010, to March 31, 2015, in Ontario, Canada, with follow-up to March 31, 2017. Patients who had a previously implanted permanent pacemaker or who died during the index hospitalization were excluded. Inverse probability of treatment weighting using the propensity score was used to adjust for baseline differences between the pacemaker and nonpacemaker groups. EXPOSURES Patients received a permanent pacemaker during the index hospitalization after transcatheter aortic valve replacement. MAIN OUTCOMES AND MEASURES All-cause mortality, readmission, readmission for heart failure, emergency department visits, and cumulative 1-year health care costs. RESULTS The study cohort consisted of 1263 patients (mean [SD] age, 82.3 [7.2] years; 595 [47.1%] female; 137 [10.8%] rural), of whom 186 (14.7%) required permanent pacemaker insertion during the index hospitalization after transcatheter aortic valve replacement. Mean follow-up was 990 days. After propensity score weighting, over the entire follow-up period, pacemaker implantation was associated with significantly higher all-cause mortality (43.9% vs 31.7%; hazard ratio [HR], 1.40; 95% CI, 1.01-1.94; P = .04), all-cause readmission (80.9% vs 70.6%; HR, 1.28; 95% CI, 1.15-1.43; P < .001), and emergency department visits (95.5% vs 87.3%; HR, 1.28; 95% CI, 1.08-1.52; P = .004). Pacemaker implantation was also associated with significantly greater readmission for heart failure (33.9% vs 19.1%; HR, 1.90; 95% CI, 1.53-2.36; P < .001). There were no statistically significant differences between groups in adjusted cumulative health care costs 1 year after discharge. CONCLUSIONS AND RELEVANCE New permanent pacemaker implantation after transcatheter aortic valve replacement was associated with significantly greater morbidity and mortality at long-term follow-up. However, this did not translate to a difference in cumulative health care costs after hospital discharge.
Collapse
Affiliation(s)
- Talal Aljabbary
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Feng Qiu
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
| | - Shannon Masih
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
| | - Jiming Fang
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
| | - Gabby Elbaz-Greener
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dennis T Ko
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sheldon Singh
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
32
|
Outcomes with a latest generation self-expandable, intra-annular, re-sheathable transcatheter heart valve system: analysis of patients with impaired left ventricular function and determinants for pacemaker implantation. Clin Res Cardiol 2018; 107:914-923. [DOI: 10.1007/s00392-018-1263-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/24/2018] [Indexed: 01/09/2023]
|
33
|
Applegate PM, Boyd WD, Applegate Ii RL, Liu H. Is it the time to reconsider the choice of valves for cardiac surgery: mechanical or bioprosthetic? J Biomed Res 2017; 31:373-376. [PMID: 28958994 PMCID: PMC5706429 DOI: 10.7555/jbr.31.20170027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Patricia M Applegate
- Department of Cardiology, University of California Davis Health, Sacramento, CA, USA
| | - W Douglas Boyd
- Department of Cardiothoracic Surgery, University of California Davis Health, Sacramento, CA, USA
| | - Richard L Applegate Ii
- Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Hong Liu
- Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| |
Collapse
|