Association of Volume and Outcomes in 234,556 Patients Undergoing Surgical Aortic Valve Replacement

Aortic valve replacement for aortic stenosis: Influence of centre volume on TAVR adoption rates and outcomes in France

BACKGROUND

Transcatheter (TAVR) has supplanted surgical (SAVR) aortic valve replacement (AVR).

AIM

To evaluate whether adoption of this technology has varied according to centre volume at the nationwide level.

METHODS

From an administrative hospital-discharge database, we collected data on all AVRs performed in France between 2007 and 2019. Centres were divided into terciles based on the annual number of SAVRs performed in 2007-2009 ("before TAVR era").

RESULTS

A total of 192,773 AVRs (134,662 SAVRs and 58,111 TAVRs) were performed in 47 centres. The annual number of AVRs and TAVRs increased significantly and linearly in low-volume (<152 SAVRs/year; median 106, interquartile range [IQR] 75-129), middle-volume (152-219 SAVRs/year; median 197, IQR 172-212) and high-volume (>219 SAVRs/year; median 303, IQR 268-513) terciles, but to a greater degree in the latter (+14, +16 and +24 AVRs/centre/year and +16, +19 and +31 TAVRs/centre/year, respectively; PANCOVA<0.001). Charlson Comorbidity Index and in-hospital death rates declined from 2010 to 2019 in all terciles (all Ptrend<0.05). In 2017-2019, after adjusting for age, sex and Charlson Comorbidity Index, there was a trend toward lower death rates in the high-volume tercile (P=0.06) for SAVR, whereas death rates were similar for TAVR irrespective of tercile (P=0.27). Similar results were obtained when terciles were defined based on number of interventions performed in the last instead of the first 3years. Importantly, even centres in the lowest-volume tercile performed a relatively high number of interventions (150 TAVRs/year/centre).

CONCLUSIONS

In a centralized public healthcare system, the total number of AVRs increased linearly between 2007 and 2019, mostly due to an increase in TAVR, irrespective of centre volume. Progressive declines in patient risk profiles and death rates were observed in all terciles; in 2017-2019 death rates were similar in all terciles, although lower in high-volume centres for SAVR.

Surgical versus transcatheter aortic valve replacement in low-risk Medicare beneficiaries

OBJECTIVE

Recent approval of transcatheter aortic valve replacement (TAVR) in patients at low surgical risk has resulted in a rapid real-world expansion of TAVR in patients not otherwise examined in recent low-risk trials. We sought to evaluate the outcomes of surgical aortic valve replacement (SAVR) versus TAVR in low-risk Medicare beneficiaries.

METHODS

Using the US Centers for Medicare and Medicaid Services claims database, we evaluated all beneficiaries undergoing isolated SAVR (n = 33,210) or TAVR (n = 77,885) (2018-2020). International Classification of Diseases 10th revision codes were used to define variables and frailty was defined by the validated Kim index. Doubly robust risk adjustment was performed with inverse probability weighting and multilevel regression models, as well as competing-risk time to event analysis. A low-risk cohort was identified to simulate recent low-risk trials.

RESULTS

A total of 15,749 low-risk patients (8144 SAVR and 7605 TAVR) were identified. Comparison was performed with doubly robust risk adjustment accounting for all factors. TAVR was associated with lower perioperative stroke (odds ratio, 0.62; P < .001) and hospital mortality (odds ratio, 0.16; P < .001) compared with SAVR. However, risk-adjusted longitudinal analysis demonstrated TAVR was associated with higher late risk of stroke (hazard ratio, 1.65; P < .001), readmission for valve reintervention (hazard ratio, 1.88; P < .001), and all-cause mortality (hazard ratio, 1.54; P < .001) compared with SAVR.

CONCLUSIONS

Among low-risk Medicare beneficiaries younger than age 75 years undergoing isolated AVR, SAVR was associated with higher index morbidity and mortality but improved 3-year risk-adjusted stroke, valve reintervention, and survival compared with TAVR.

Age-Stratified Surgical Aortic Valve Replacement for Aortic Stenosis

BACKGROUND

The management of aortic stenosis has evolved to stratification by age as reflected in recent societal guidelines. We evaluated age-stratified surgical aortic valve replacement (SAVR) trends and outcomes in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) from The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

METHODS

This cohort included adults (≥18 years) undergoing SAVR for severe aortic stenosis between July 2011 and December 2022. Comparisons were stratified by age (<65 years, 65-79 years, ≥80 years) and BAV or TAV status. Primary end points included operative mortality, composite morbidity and mortality, and permanent stroke. Observed to expected ratios by The Society of Thoracic Surgeons predicted risk of mortality were calculated.

RESULTS

In total, 200,849 SAVR patients (55,326 BAV [27.5%], 145,526 TAV [72.5%]) from 1238 participating hospitals met study criteria. Annual SAVR volumes decreased by 45% (19,560 to 10,851) during the study period. The decrease was greatest (96%) for patients ≥80 years of age (4914 to 207). The relative prevalence of BAV was greater in younger patients (<65 years, 69,068 [49.5% BAV]; 65-79 years, 104,382 [19.1% BAV]; ≥80 years, 27,399 [4.5% BAV]). The observed mortality in <80-year-old BAV patients (<65 years, 1.08; 65-79 years, 1.21; ≥80 years, 3.68) was better than the expected mortality rate (<65 years, 1.22; 65-79 years, 1.54; ≥80 years, 3.14).

CONCLUSIONS

SAVR volume in the transcatheter era has decreased substantially, particularly for patients ≥80 years old and for those with TAV. Younger patients with BAV have better than expected outcomes, which should be carefully considered during shared decision-making in the treatment of aortic stenosis. SAVR should remain the preferred therapy in this population.

Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation: Current Status in Korea

BACKGROUND

In the era of transcatheter aortic valve implantation, this study was conducted to investigate the current trend of aortic valve procedures in Korea and to evaluate the early and mid-term outcomes of isolated surgical aortic valve replacement (SAVR) using bioprosthetic valves in contemporary Korea.

METHODS

Contemporary outcomes of isolated bioprosthetic SAVR in Korea were analyzed using the datasets on a multicenter basis. Patients who underwent isolated SAVR using bioprostheses from June 2015 to May 2019 were included, and those with concomitant cardiac procedures, SAVR with mechanical valve, or SAVR for infective endocarditis were excluded. A total of 456 patients from 4 large-volume centers were enrolled in this study. Median follow-up duration was 43.4 months. Early postoperative outcomes, mid-term clinical outcomes, and echocardiographic outcomes were evaluated.

RESULTS

Mean age of the patients was 73.1 ± 7.3 years, and EuroSCORE II was 2.23 ± 2.09. The cardiopulmonary bypass time and aortic cross-clamp times were median 106 and 76 minutes, respectively. SAVR was performed with full median sternotomy (81.8%), right thoracotomy (14.7%), or partial sternotomy (3.5%). Operative mortality was 1.8%. The incidences of stroke and permanent pacemaker implantation were 1.1% and 1.1%, respectively. Paravalvular regurgitation ≥ mild was detected in 2.6% of the patients. Cumulative incidence of all-cause mortality at 5 years was 13.0%. Cumulative incidences of cardiovascular mortality and bioprosthetic valve dysfunction at 5 years were 7.6% and 6.8%, respectively.

CONCLUSION

The most recent data for isolated SAVR using bioprostheses in Korea resulted in excellent early and mid-term outcomes in a multicenter study.

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension in Cape Town, South Africa

Background

Pulmonary endarterectomy (PEA) is the only definitive and potentially curative therapy for chronic thromboembolic pulmonary hypertension (CTEPH), associated with impressive improvements in symptoms and haemodynamics. However, it is only offered at a few centres in South Africa. The characteristics and outcomes of patients undergoing PEA in Cape Town have not been reported previously.

Objectives

To assess the difference in World Health Organization functional class (WHO-FC) before and at least 6 weeks after surgery.

Methods

We interrogated the adult cardiothoracic surgery database at the University of Cape Town between December 2005 and April 2021 for patients undergoing PEA at Groote Schuur Hospital and a private hospital.

Results

A total of 32 patients underwent PEA, of whom 8 were excluded from the final analysis owing to incomplete data or a histological diagnosis other than CTEPH. The work-up of these patients for surgery was variable: all had a computed tomography pulmonary angiogram, 7 (29%) had a ventilation/perfusion scan, 5 (21%) underwent right heart catheterisation, and none had a pulmonary angiogram. The perioperative mortality was 4/24 (17%): 1 patient (4%) had a cardiac arrest on induction of anaesthesia, 2 patients (8%) died of postoperative pulmonary haemorrhage, and 1 patient (4%) died of septic complications in the intensive care unit. Among the survivors, the median (interquartile range) improvement in WHO-FC was 2 (1 - 3) classes (p=0.0004); 10/16 patients (63%) returned to a normal baseline (WHO-FC I).

Conclusion

Even in a low-volume centre, PEA is associated with significant improvements in WHO-FC and a return to a normal baseline in survivors.

Study synopsis

What the study adds. South African patients undergoing pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have a marked improvement in functional status, with many returning to a normal functional baseline. However, the small number of patients included in this study indicates that PEA is probably underutilised. Pre- and postoperative assessment is inconsistent, despite availability of established guidelines.Implications of the findings. More patients should be referred to specialist centres for assessment for this potentially curative procedure. Use of guidelines to standardise investigations and monitoring of patients with CTEPH may improve patient selection for surgery.

Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US

Importance

Professional societies and the Centers for Medicare & Medicaid Services suggest volume thresholds to ensure quality in transcatheter aortic valve implantation (TAVI).

Objective

To model the association of volume thresholds vs spoke-and-hub implementation of outcome thresholds with TAVI outcomes and geographic access.

Design, Setting, and Participants

This cohort study included patients who enrolled in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. Site volume and outcomes were determined from a baseline cohort of adults undergoing TAVI between July 1, 2017, and June 30, 2020.

Exposures

Within each hospital referral region, TAVI sites were categorized by volume (<50 or ≥50 TAVIs per year) and separately by risk-adjusted outcome on the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy 30-day TAVI composite during the baseline period (July 2017 to June 2020). Outcomes of patients undergoing TAVIs from July 1, 2020, to March 31, 2022, were then modeled as though the patients had been treated at (1) the nearest higher volume (≥50 TAVIs per year) or (2) the best outcome site within the hospital referral region.

Main Outcomes and Measures

The primary outcome was the absolute difference in events between the adjusted observed and modeled 30-day composite of death, stroke, major bleeding, stage III acute kidney injury, and paravalvular leak. Data are presented as the number of events reduced under the above scenarios with 95% bayesian credible intervals (CrIs) and median (IQR) driving distance.

Results

The overall cohort included 166 248 patients with a mean (SD) age of 79.5 (8.6) years; 74 699 (47.3%) were female and 6657 (4.2%) were Black; 158 025 (95%) were treated in higher-volume sites (≥50 TAVIs) and 75 088 (45%) were treated in best-outcome sites. Modeling a volume threshold, there was no significant reduction in estimated adverse events (-34; 95% CrI, -75 to 8), while the median (IQR) driving time from the existing site to the alternate site was 22 (15-66) minutes. Transitioning care to the best outcome site in a hospital referral region resulted in an estimated 1261 fewer adverse outcomes (95% CrI, 1013-1500), while the median (IQR) driving time from the original site to the best site was 23 (15-41) minutes. Directionally similar findings were observed for Black individuals, Hispanic individuals, and individuals from rural areas.

Conclusions and Relevance

In this study, compared with the current system of care, a modeled outcome-based spoke-and-hub paradigm of TAVI care improved national outcomes to a greater extent than a simulated volume threshold, at the cost of increased driving time. To improve quality while maintaining geographic access, efforts should focus on reducing site variation in outcomes.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.

Transcatheter and Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valve Stenosis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is not widely used in patients with bicuspid aortic valve (BAV) disease and has not yet been studied in randomized clinical trials. We characterized the rate of use and outcomes of TAVR and surgical aortic valve replacement (SAVR) in patients with BAV.

METHODS

Adults with BAV stenosis receiving SAVR or TAVR procedures were abstracted from the 2012 to 2019 Nationwide Readmissions Database (NRD). Risk-adjusted analyses were performed with NRD-provided weights and inverse probability of treatment weights (IPTW) to examine the association of treatment strategy on inpatient mortality, complications, and hospitalization resource utilization. Nonelective readmissions within 90 days of discharge and reintervention at the first readmission were also examined.

RESULTS

Of an estimated 56 331 patients with BAV requiring aortic valve replacement, 6.8% underwent TAVR. Unadjusted analysis demonstrated higher index hospitalization mortality for TAVR compared with SAVR. Upon risk adjustment using NRD-provided weights, the odds of pacemaker implantation remained significantly higher for TAVR patients compared with SAVR, with no significant difference in mortality. When NRD-provided survey weights were applied, TAVR had higher rates of 90-day readmission. Adjustment with inverse probability of treatment weights resolved these differences between the 2 groups. Regardless of the risk-adjustment method, the odds of reintervention were consistently higher among BAV TAVR patients compared with SAVR.

CONCLUSIONS

The present analysis demonstrates comparable in-hospital mortality and morbidity for TAVR and SAVR patients in the moderate-risk era. With increasing TAVR use in BAV, surgeons must further refine selection criteria with consideration of concomitant aortopathy and implications of reintervention.

Orthopaedic, trauma surgery, and Covid-2019 pandemic: clinical panorama and future prospective in Europe

Purpose

This study investigated the impact of the Covid-19 pandemic in Europe on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery. Strategies to resume the clinical activities were also discussed.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. All the comparative studies reporting data on the impact of Covid-19 in the field of orthopaedic and trauma surgery in Europe were accessed. Only comparative clinical studies which investigated the year 2020 versus 2019 were eligible.

Results

57 clinical investigations were included in the present study. Eight studies reported a reduction of the orthopaedic consultations, which decreased between 20.9 and 90.1%. Seven studies reported the number of emergency and trauma consultations, which were decreased between 37.7 and 74.2%. Fifteen studies reported information with regard to the reasons for orthopaedic and trauma admissions. The number of polytraumas decreased between 5.6 and 77.1%, fractures between 3.9 and 63.1%. Traffic accidents admissions dropped by up to 88.9%, and sports-related injuries dropped in a range of 59.3% to 100%. The overall reduction of the surgical interventions ranged from 5.4 to 88.8%.

Conclusion

The overall trend of consultations, surgeries, and rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the pre-pandemic era. Given the heterogeneities in the clinical evidence, results from the present study should be considered carefully.

Level of evidence

Level IV, systematic review.

Disparities in coronary artery bypass grafting between high and low volume surgeons and hospitals

Background

High-volume surgeons and hospitals performing coronary artery bypass grafting have been associated with improved patient outcomes. However, patients of increased socioeconomic distress may have worse outcomes because of health care disparities. We sought to identify trends and outcomes in patients of elevated distress undergoing bypass grafting.

Methods

The Florida Agency for Healthcare Administration administrative data set was merged with Centers for Medicare and Medicaid Services Physician and Hospital Compare and Economic Innovation Group Distressed Community Index data sets to build a comprehensive database. The data set was queried to identify patients undergoing coronary artery bypass procedures between 2016 and 2020. High- and low-volume hospitals and surgeons were compared. Patient and hospital demographics, comorbidities, length of stay, and postoperative complications were analyzed by χ² and t test where appropriate.

Results

A total of 41,571 coronary artery bypass grafting procedures were performed by 174 surgeons at 67 Florida hospitals. Low- and high-volume hospitals did not differ with respect to hospital ownership, overall star rating, national comparisons of mortality, readmission, or cost effectiveness. Patients from at-risk and distressed communities were more likely to undergo surgery at low-volume hospitals. Hospital length of stay was increased for low-volume hospitals (10.2 vs 9.4 days, P < .05). Postoperative complications including pneumonia, arrhythmia, respiratory failure, acute renal failure, shock, pleural effusion, and sepsis were more frequent at low-volume hospitals and for low-volume surgeons.

Conclusion

High-volume hospitals and surgeons have improved postoperative outcomes and hospital length of stay when compared to low-volume hospitals and surgeons performing coronary artery bypass grafting. At-risk and distressed populations are more likely to undergo bypass surgery at low-volume hospitals, potentially contributing to worse patient outcome. Efforts should be made to mitigate the potential impact of low socioeconomic status to improve outcomes in this population.