Outcomes of Patients With Severe Chronic Lung Disease Who Are Undergoing Transcatheter Aortic Valve Replacement

Impact of age on outcomes after transcatheter aortic valve implantation

AIMS

Usage of transcatheter aortic valve implantation (TAVI) for treatment of severe aortic stenosis is increasing across age groups. However, literature on age-specific TAVI outcomes is lacking. The purpose of this study is to assess the risks of procedural complications, mortality, and readmission in patients undergoing TAVI across different age groups.

METHODS AND RESULTS

The Nationwide Readmissions Database was used to identify 84 017 patients undergoing TAVI from 2016 to 2018. Patients were stratified into four age groups: younger than 70, 70-79, 80-89, and older than 90. Complications, mortality, and readmission rates were compared between groups in a proportional hazards regression model. Risk of post-procedural stroke, acute kidney injury, and pacemaker or implantable cardioverter defibrillator implantation increased with incremental age grouping. Compared with patients younger than 70, patients aged 70-79 had no significant difference in mortality, whereas patients aged 80-89 and older than 90 had an increased mortality risk [odds ratio (OR) 1.39, confidence interval (CI) 1.14-1.70, P = 0.001 and OR 1.68, CI 1.33-2.12, P < 0.001, respectively]. Patients aged 80-89 and older than 90 had increased overall readmission compared with patients younger than 70 (HR 1.09, CI 1.03-1.14, P = 0.001 and HR 1.33, CI 1.25-1.41, P < 0.001, respectively). Cardiac readmissions followed the same trend.

CONCLUSION

Patients aged 80-89 and older than 90 undergoing TAVI have increased risk of readmission, complications, and mortality compared with patients younger than 70.

Readmission rates and risk factors for readmission after transcatheter aortic valve replacement in patients with end-stage renal disease

Objectives

We sought to examine readmission rates and predictors of hospital readmission following TAVR in patients with ESRD.

Background

End-stage renal disease (ESRD) is associated with poor outcomes following transcatheter aortic valve replacement (TAVR).

Methods

We assessed index hospitalizations for TAVR from the National Readmissions Database from 2017 to 2018 and used propensity scores to match those with and without ESRD. We compared 90-day readmission for any cause or cardiovascular cause. Length of stay (LOS), mortality, and cost were assessed for index hospitalizations and 90-day readmissions. Multivariable logistic regression was performed to identify predictors of 90-day readmission.

Results

We identified 49,172 index hospitalizations for TAVR, including 1,219 patients with ESRD (2.5%). Patient with ESRD had higher rates of all-cause readmission (34.4% vs. 19.2%, HR 1.96, 95% CI 1.68–2.30, p<0.001) and cardiovascular readmission (13.2% vs. 7.7%, HR 1.85, 95% CI 1.44–2.38, p<0.001) at 90 days. During index hospitalization, patients with ESRD had longer length of stay (mean difference 1.9 days), increased hospital cost (mean difference $42,915), and increased in-hospital mortality (2.6% vs. 0.9%). Among those readmitted within 90 days, patients with ESRD had longer LOS and increased hospital charge, but similar in-hospital mortality. Diabetes (OR 1.86, 95% CI 1.31–2.64) and chronic pulmonary disease (OR 1.51, 95% CI 1.04–2.18) were independently associated with higher odds of 90-day readmission in patients with ESRD.

Conclusion

Patients with ESRD undergoing TAVR have higher mortality and increased cost associated with their index hospitalization and are at increased risk of readmission within 90 days following TAVR.

Transcatheter aortic valve replacement in patients with severe comorbidities: A retrospective cohort study

OBJECTIVE

To investigate the long-term outcomes of patients with severe comorbidities (sCM) undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

The benefit of TAVR may be limited among patients with sCM due to a lack of mortality- or quality-of-life-benefit.

METHODS

All TAVR patients in the Allina Health System between January 1, 2011 and August 7, 2018 were included (n = 890, 82 ± 8 years, 55% men). sCM included: severe lung disease, severe liver disease, end-stage renal disease, severe, severe dementia, severe dilated cardiomyopathy, and frailty. Outcomes between patients with (n = 215, 24%) and without (n = 675, 76%) sCM were compared.

RESULTS

At baseline, patients with sCM had worse symptoms, higher STS-PROM and a lower Kansas City Cardiomyopathy Questionnaire (KCCQ) score compared to those without. During a median follow-up of 15 months (IQR, 7-29 months), there were 208 (23%) deaths. Patients with sCM had a lower 3-year survival free from all-cause mortality (40% vs. 79%, p < .001), and lower 3-year survival free from the composite endpoint of all-cause mortality, re-hospitalization for heart failure, myocardial infarction or stroke (31% vs. 64%, p < .001) compared to those without sCM. The estimated monthly increase in KCCQ scores following TAVR was 1.5, 95%CI (1.3, 1.7), p < .001 irrespective of sCM grouping. From Cox regression analysis, severe comorbidities, with the exception of liver disease, were associated with an increased risk of all-cause mortality and any additional comorbidity was associated with a multiplicative increase in risk of mortality of 2.8 (95%CI 2.3, 3.6), p < .001.

CONCLUSIONS

TAVR patients with sCM have poor 3-year outcomes but may experience improvements in their quality of life.

2019 Canadian Cardiovascular Society Position Statement for Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) or replacement has rapidly changed the treatment of patients with severe symptomatic aortic stenosis. It is now the standard of care for patients believed to be inoperable or at high surgical risk, and a reasonable alternative to surgical aortic valve replacement for those at intermediate surgical risk. Recent clinical trial data have shown the benefits of this technology in patients at low surgical risk as well. This update of the 2012 Canadian Cardiovascular Society TAVI position statement incorporates clinical evidence to provide a practical framework for patient selection that does not rely on surgical risk scores but rather on individual patient evaluation of risk and benefit from either TAVI or surgical aortic valve replacement. In addition, this statement features new wait time categories and treatment time goals for patients accepted for TAVI. Institutional requirements and recommendations for operator training and maintenance of competency have also been revised to reflect current standards. Procedural considerations such as decision-making for concomitant coronary intervention, antiplatelet therapy after intervention, and follow-up guidelines are also discussed. Finally, we suggest that all patients with aortic stenosis might benefit from evaluation by the heart team to determine the optimal individualized treatment decision.

Fibrotic Lung Disease at CT Predicts Adverse Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

Purpose

To evaluate the relationship between CT findings of diffuse lung disease and post-transcatheter aortic valve replacement (TAVR) outcomes.

Materials and Methods

Retrospective review of pre-TAVR CT scans obtained during 2012-2017 was conducted. Emphysema, reticulation, and honeycombing were separately scored using a five-point scale and applied to 10 images per examination. The fibrosis score was the sum of reticulation and honeycombing scores. Lung diseases were also assessed as dichotomous variables (zero vs nonzero scores). The two outcomes evaluated were death and the composite of death and readmission.

Results

The study included 373 patients with median age of 84 years (age range, 51-98 years; interquartile range, 79-88 years) and median follow-up of 333 days. Fibrosis and emphysema were present in 66 (17.7%) and 95 (25.5%) patients, respectively. Fibrosis as a dichotomous variable was independently associated with the composite of death and readmission (hazard ratio [HR], 1.54; P = .030). In those without known chronic lung disease (CLD) (HR, 3.09; P = .024) and those without airway obstruction, defined by a ratio of forced expiratory volume in 1 second to the forced vital capacity greater than or equal to 70% (HR, 1.67, P = .039), CT evidence of fibrosis was a powerful predictor of adverse events. Neither emphysema score nor emphysema as a dichotomous variable was an independent predictor of outcome.

Conclusion

The presence of fibrosis on baseline CT scans was an independent predictor of adverse events after TAVR. In particular, fibrosis had improved predictive value in both patients without known CLD and patients without airway obstruction.Supplemental material is available for this article.© RSNA, 2020.

Transcatheter aortic valve replacement in patients with paradoxical low-flow, low-gradient aortic stenosis: Incidence and predictors of treatment futility

BACKGROUND

Few and controversial data exist on the outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLFLG-AS) following transcatheter aortic valve replacement (TAVR). This study aims to better characterize clinical outcomes and predictors of treatment futility in PLFLG-AS patients undergoing TAVR.

METHODS

In this multicenter study, 318 patients with PLFLG-AS undergoing TAVR were categorized according to treatment futility, defined as all-cause mortality, poor functional status (NYHA class III-IV) or deterioration in functional class at 1-year follow-up. Clinical outcomes and the factors associated with treatment futility were assessed.

RESULTS

The mean age of the patients was 81.0 ± 8.3 years and 50.3% were women. At 1-year follow-up, 17.6% died and 12.9% had heart failure hospitalization. Residual impaired functional capacity (NYHA ≥ II) was present in 54.4% of patients who were alive at 1-year, and 9.8% remained in NYHA III/IV. The primary endpoint was observed in 103 (32.4%) patients, of which 54% died and 46% had a poor or worsening functional class. Factors independently associated with treatment futility were the presence of atrial fibrillation (AF) (OR:1.79, 95%CI, 1.04-3.10), chronic obstructive pulmonary disease (COPD) (OR:2.66, 95%CI, 1.50-4.74) and a lower SVi (OR per each decrease in 10 ml/m²:1.89, 95%CI, 1.06-3.45). The risk of treatment futility of patients with AF, COPD and a SVi < 30 ml/m² was 66.38% (95%CI, 54.29%-78.48%).

CONCLUSION

Close to one-third of patients with PLFLG-AS failed to derive a benefit from TAVR. The presence of AF, COPD and a low SVi were predictors of treatment futility. Being able to identify patients less likely to improve after the procedure may help to guide management and improve outcomes in patients with PLFLG-AS.

Significance of Interstitial Lung Disease on Outcomes Following Cardiac Surgery

Interstitial lung disease (ILD) is a known risk factor for noncardiac surgery due to acute pulmonary exacerbations but its impact after cardiac surgery is not known. We examined perioperative outcomes and risk factors for long-term survival in ILD patients who underwent cardiac surgery. From January 2002 to June 2017, 294 cardiac surgery patients with a previous ILD diagnosis, including 75 patients with idiopathic pulmonary fibrosis (IPF), were identified. A comparison cohort of 1,481 non-ILD patients was selected based on a priori variables. Long-term survival was evaluated using Cox proportional hazard modeling. Median follow-up was 6.4 years. ILD patients had higher postoperative mortality, reintubation rates, longer intensive care unit stay, and higher 30-day readmission rates (all p <0.05). Kaplan-Meier estimates of survival at 1, 5, and 10 years were 89%, 62%, and 37% for the non-IPF ILD cohort, 89%, 50%, and 13% for the IPF cohort, and 95%, 82%, and 67% for the comparison cohort, respectively (overall p <0.001). These significant differences in survival persisted in our risk-adjusted survival analysis. Adjusted survival analysis identified IPF (hazard ratio 3.04) and ILD (non-IPF; hazard ratio 1.78) as significant contributors to all-cause mortality. However, there were no changes in pulmonary function tests after 48 months postprocedure. In conclusion, ILD patients who underwent cardiac surgery have increased operative mortality, reintubation rates, longer intensive care unit, and higher 30-day readmissions compared with non-ILD patients. Moreover, severity of ILD, especially in IPF, appears to be associated with shorter long-term survival. In these patients, pulmonary risk stratification and multidisciplinary team approach are crucial.

National trend of utilization, clinical and economic outcomes of transcatheter aortic valve replacement among patients with chronic obstructive pulmonary disease

Objectives: We aimed to trend the utilization of transcatheter aortic valve replacement (TAVR) among COPD patients, compare its outcomes to surgical aortic valve replacement (SAVR) and assess any social disparities in its outcomes. Background: Patients with chronic obstructive pulmonary disease (COPD) have been increasingly undergoing TAVR, but studies to evaluate the national trend of TAVR utilization and outcomes are still lacking. Methods: We conducted a retrospective observational study using a nationally representative database, the National Inpatient Sample (NIS). Results: From 2010 to 2014, the proportion of TAVR among COPD patients has increased from <1% to >50%. Patients who underwent TAVR were older, more likely to be women or white, carried more public insurance and had more comorbidities. There was no overall difference in mortality between TAVR and SAVR (2.74% vs. 2.59%, p = .860), and it has been consistently similar over time. However, patients with TAVR had shorter length of stay in the hospital after the procedure and were more likely to be discharged home than the SAVR group. Among the TAVR group, there were no gender, race or insurance disparities for in-hospital mortality, but female gender was related to lower discharge home rate, higher cost and longer stay in hospital. Conclusions: The rate of TAVR among COPD patients has been increasing nationally since 2011. In spite of higher comorbidities, TAVR did not show a difference in hospital mortality compared to SAVR but demonstrated shorter length of stay and more home discharges. This suggests that TAVR is a viable and potentially better option for patients with COPD.

Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Lower-Surgical-Risk Patients With Chronic Obstructive Pulmonary Disease

Respiratory complications are a major factor contributing to postoperative morbidity and mortality, especially in patients with chronic obstructive pulmonary disease (COPD). Our objective was to compare the rate of respiratory complications in patients with COPD with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR). Low-to-intermediate surgical-risk patients with moderate or severe COPD who underwent TAVI or SAVR at 2 tertiary centers were included in this study. COPD was defined by the Global Initiative for Chronic Lung Disease classification. The primary end point was the 30-day composite of respiratory mortality, prolonged ventilation (>24 hours), the need for reintubation for respiratory causes, tracheostomy, acute respiratory distress syndrome, pneumonia, or pneumothorax. The inverse probability of treatment weighting was determined to reduce baseline imbalance between the 2 groups. A total of 321 patients (mean age 72.4 ± 9.3 years old, 74.5% male, mean Society of Thoracic Surgeons predicted risk of mortality 3.8 ± 1.9%, mean forced expiratory volume 1: 59 ± 13%) were included in the analysis. TAVI was performed in 122 patients, whereas 199 underwent SAVR. There were no differences between the 2 groups regarding the composite respiratory primary end point (SAVR 10.6%, TAVR 7.4%, adjusted odds ratio 0.57, 95% confidence interval 0.20 to 1.65, p = 0.30). Transfemoral TAVI without general anesthesia (28 patients) was associated with the lowest rate of respiratory complications (3.6%). Among patients with moderate or severe COPD at low-to-intermediate surgical risk, TAVI patients had a similar rate of 30-day major pulmonary complications compared with SAVR patients despite a higher baseline risk profile. Future studies should further investigate whether TAVI is associated with reduced respiratory complications, comparing transfemoral TAVI recipients treated with local anesthesia with their SAVR counterparts.

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.

Quality and Safety in Health Care, Part XXXI: Selected Risk Factors for Transcatheter Aortic Valve Replacement

The Transcatheter Valve Therapy Registry has been very helpful in providing data to better understand patient risk factors for transcatheter aortic valve replacement (TAVR). The outcome of TAVR depends on many patient indicators, some of which are given in this article, including the age, dependence on oxygen, classification of pulmonary disease, gender, and the speed of walking. Patient characteristics also help determine which approach will be used to place the device. There are models for the outcome of the TAVR procedure now and more being developed.

Etiologies and Predictors of 30-Day Readmission and In-Hospital Mortality During Primary and Readmission After Transcatheter Aortic Valve Implantation

There are sparse data on the etiologies and predictors of readmission after transcatheter aortic valve implantation (TAVI). The study cohort was derived from the National Readmission Data 2013, a subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. TAVI was identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. The coprimary outcomes were 30-day readmissions and in-hospital mortality during primary admission and readmission. Hierarchical 2-level logistic models were used to evaluate study outcomes. Our analysis included 5,702 (weighted n = 12,703) TAVI procedures. About 1,215 patients were readmitted (weighted n = 2,757) within 30 days during the study year. Significant predictors of readmission included transapical access (OR, 95% CI, p value) (1.23, 1.10 to 1.38, <0.01), diabetes (1.18, 1.06 to 1.32, p 0.004), chronic lung disease (1.32, 1.18 to 1.47, <0.01), renal failure (1.43, 1.24 to 1.65, <0.01), patients discharged to facilities (1.28, 1.14 to 1.43, <0.01), and those who had lengthier hospital stays during primary admission (length of stay >10 days: 3.06, 2.22 to 4.22, <0.01). Female gender (1.39, 1.16 to 1.68, <0.01), blood transfusion (1.88, 1.55 to 2.29, <0.01), use of vasopressors (3.63, 2.50 to 5.28, <0.01), hemodynamic support (6.39, 5.20 to 7.85, <0.01) and percutaneous coronary intervention (1.89, 1.30 to 2.74, 0.01) during primary admission were significant predictors of in-hospital mortality. Age and transapical access were significant predictors of in-hospital mortality during readmission. In conclusion, heart failure, pneumonia, and bleeding complications are among important etiologies of readmission in patients after TAVI. Patients who underwent transapical TAVI and those with slower in-hospital recovery and co-morbidities such as chronic lung disease and renal failure are more likely to be readmitted to the hospital.

[Non-cardiac aspects of aortic stenosis in the elderly: A review]

Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?