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Blank M, Robitaille MJ, Wachtendorf LJ, Linhardt FC, Ahrens E, Strom JB, Azimaraghi O, Schaefer MS, Chu LM, Moon JY, Tarantino N, Nair SR, Thalappilil R, Tam CW, Leff J, Di Biase L, Eikermann M. Loss of Independent Living in Patients Undergoing Transcatheter or Surgical Aortic Valve Replacement: A Retrospective Cohort Study. Anesth Analg 2023; 137:618-628. [PMID: 36719955 DOI: 10.1213/ane.0000000000006377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The recommendation for transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in patients 65 to 80 years of age is equivocal, leaving patients with a difficult decision. We evaluated whether TAVR compared to SAVR is associated with reduced odds for loss of independent living in patients ≤65, 66 to 79, and ≥80 years of age. Further, we explored mechanisms of the association of TAVR and adverse discharge. METHODS Adult patients undergoing TAVR or SAVR within a large academic medical system who lived independently before the procedure were included. A multivariable logistic regression model, adjusting for a priori defined confounders including patient demographics, preoperative comorbidities, and a risk score for adverse discharge after cardiac surgery, was used to assess the primary association. We tested the interaction of patient age with the association between aortic valve replacement (AVR) procedure and loss of independent living. We further assessed whether the primary association was mediated (ie, percentage of the association that can be attributed to the mediator) by the procedural duration as prespecified mediator. RESULTS A total of 1751 patients (age median [quartiles; min-max], 76 [67, 84; 23-100]; sex, 56% female) were included. A total of 27% (222/812) of these patients undergoing SAVR and 20% (188/939) undergoing TAVR lost the ability to live independently. In our cohort, TAVR was associated with reduced odds for loss of independent living compared to SAVR (adjusted odds ratio [OR adj ] 0.19 [95% confidence interval {CI}, 0.14-0.26]; P < .001). This association was attenuated in patients ≤65 years of age (OR adj 0.63 [0.26-1.56]; P = .32) and between 66 and 79 years of age (OR adj 0.23 [0.15-0.35]; P < .001), and magnified in patients ≥80 years of age (OR adj 0.16 [0.10-0.25]; P < .001; P -for-interaction = .004). Among those >65 years of age, a shorter procedural duration mediated 50% (95% CI, 28-76; P < .001) of the beneficial association of TAVR and independent living. CONCLUSIONS Patients >65 years of age undergoing TAVR compared to SAVR had reduced odds for loss of independent living. This association was partly mediated by shorter procedural duration. No association between AVR approach and the primary end point was found in patients ≤65 years of age.
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Affiliation(s)
- Michael Blank
- From the Department of Anesthesia, Critical Care & Pain Medicine
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | | | - Luca J Wachtendorf
- From the Department of Anesthesia, Critical Care & Pain Medicine
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Felix C Linhardt
- From the Department of Anesthesia, Critical Care & Pain Medicine
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Elena Ahrens
- From the Department of Anesthesia, Critical Care & Pain Medicine
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Omid Azimaraghi
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Maximilian S Schaefer
- From the Department of Anesthesia, Critical Care & Pain Medicine
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Louis M Chu
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Nicola Tarantino
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Singh R Nair
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Richard Thalappilil
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Christopher W Tam
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Jonathan Leff
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York City, New York
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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