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Amin S, Baron SJ, Galper BZ. Aortic valve replacement today: Outcomes, costs, and opportunities for improvement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:78-86. [PMID: 38388246 DOI: 10.1016/j.carrev.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
The introduction of transcatheter aortic valve replacement (TAVR) just two decades ago has transformed the treatment of severe symptomatic aortic stenosis. TAVR has not only extended the option of aortic valve replacement to patients deemed ineligible for surgery, it has also demonstrated similar or better short- and intermediate-term clinical outcomes compared with surgical aortic valve replacement (SAVR) in patients at all levels of surgical risk. These benefits have been achieved with similar or lower costs compared with SAVR, at least in the first 1-2 years for intermediate- and low-risk patients. Longer-term data will further inform clinical and shared decision-making. SUMMARY FOR ANNOTATED TABLE OF CONTENTS: In just over two decades, transcatheter aortic valve replacement has emerged as a frontline approach for appropriately selected patients with severe aortic stenosis. A growing body of evidence documents similar or better clinical outcomes and cost-effectiveness for transcatheter compared with surgical aortic valve replacement. Whether the mode is transcatheter or surgical, aortic valve replacement remains underutilized in patients with clear indications for intervention.
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Affiliation(s)
- Sameer Amin
- L.A. Care Health Plan, 1055 W. 7th St, 10th Floor, Los Angeles, CA 90017, United States
| | - Suzanne J Baron
- Interventional Cardiovascular Research, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States; Outcomes Research, Baim Institute for Clinical Research, 930 W. Commonwealth Ave., Boston, MA 02215, United States
| | - Benjamin Z Galper
- Structural Heart Disease Program, Mid-Atlantic Permanente Medical Group, 8008 Westpark Dr., McLean, VA 22102, United States; Cardiac Catheterization Laboratory, Virginia Hospital Center, 1701 N. George Mason Dr., Arlington, VA 22205, United States.
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Butala AD, Nanayakkara S, Navani RV, Palmer S, Noaman S, Haji K, Htun NM, Walton AS, Stub D. Incidence, Predictors, and Outcomes of Nonhome Discharge Following Transcatheter Aortic Valve Implantation: A Multicenter Australian Experience-The NHD TAVI Study. Am J Cardiol 2024; 220:94-101. [PMID: 38583699 DOI: 10.1016/j.amjcard.2024.04.001] [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: 01/08/2024] [Revised: 03/10/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
Patients who undergo transcatheter aortic valve implantation (TAVI) commonly experience nonhome discharge (NHD), a phenomenon associated with increased health care expenditure and possibly poorer outcomes. Despite its clinical relevance in TAVI, the incidence and predictors of NHD and its impact on the quality of life remain poorly characterized. Also unknown is the proportion of patients who undergo TAVI that require long-term residential care after initial NHD. Therefore, we aimed to address these questions using a large, multicenter Australian cohort. A total of 2,229 patients who underwent TAVI from 2010 to 2023 included in the Alfred-Cabrini-Epworth TAVI Registry were analyzed. The median age was 82 (interquartile range 78 to 86) years and 41% were women. A total of 257 patients (12%) were not discharged home after TAVI, with the incidence falling over time (R2 = 0.636, p <0.001). A multivariable logistic regression model for NHD prediction was developed with excellent calibration and discrimination (C-statistic = 0.835). The independent predictors of NHD were postprocedural stroke (adjusted odds ratio [aOR] 11.05), procedure at a private hospital (aOR 3.01), living alone (aOR 2.35), vascular access site complications (aOR 2.09), frailty (aOR 1.89), age >80 years (aOR 1.82), hypoalbuminemia (aOR 1.76), New York Heart Association III to IV (aOR 1.74), and hospital length of stay (aOR 1.13) (all p <0.05). NHD was not associated with mortality at 30 days and <1% of all patients required longer-term residential care. In conclusion, although common after TAVI, NHD does not predict short-term mortality, most patients successfully return home within 30 days, and when used appropriately, NHD may serve as a brief and effective method of optimizing functional status without compromising long-term independence.
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Affiliation(s)
- Anant D Butala
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Victoria, Australia
| | - Rohan V Navani
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sonny Palmer
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Epworth Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Nay M Htun
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Antony S Walton
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Epworth Hospital, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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Strange JE, Nouhravesh N, Schou M, Christensen DM, Holt A, Østergaard L, Køber L, Olesen JB, Fosbøl EL. High-risk admission prior to transcatheter aortic valve replacement and subsequent outcomes. Am Heart J 2024; 268:53-60. [PMID: 37972676 DOI: 10.1016/j.ahj.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Severe, symptomatic aortic stenosis may cause heart failure, acute myocardial infarction, or syncope; limited data exist on the occurrence of such events before transcatheter aortic valve replacement (TAVR) and their impact on subsequent outcomes. Thus, we investigated the association between a preceding event and outcomes after TAVR. METHODS From 2014 to 2021 all Danish patients who underwent TAVR were included. Preceding events up to 180 days before TAVR were identified. A preceding event was defined as a hospitalization for heart failure, acute myocardial infarction, or syncope. The 1-year risk of all-cause death, and cardiovascular or all-cause hospitalization was compared for patients with versus without a preceding event using Kaplan-Meier, Aalen-Johansen, and in Cox regression analyses adjusted for patient characteristics. RESULTS Of 5,851 patients included, 759 (13.0%) had a preceding event. The median age was 81 years in both groups. Male sex and frailty were more prevalent in patients with a preceding event (males: 64.7% vs 55.2%, frailty: 49.6% vs 40.6%). The most common type of preceding event was a hospitalization for heart failure (n = 524). For patients with a preceding event, the 1-year risk of death was 11.7% (95% CI: 9.4%-14.1%) versus 8.0% (95% CI: 7.2%-8.7%) for patients without. The corresponding adjusted hazard ratio (aHR) was 1.29 (95%CI: 1.01-1.64). Mortality was highest for patients with a preceding event of a heart failure admission (1-year risk: 13.5% [95%CI: 10.5%-16.5%]). Comparing patients with a preceding event to those without, the 1-year risk for cardiovascular rehospitalization was 15.0% versus 8.2% (aHR 1.60 [95%CI: 1.29-1.99]) and 57.6% versus 50.6% for all-cause rehospitalization (aHR 1.08 [95%CI: 0.87-1.20]). CONCLUSIONS A hospitalization for heart failure, myocardial infarction, or syncope prior to TAVR was associated with a poorer prognosis and could represent a group to focus resource management on. Interventions to prevent preceding events and improvements in pre- and post-TAVR optimization of these patients are warranted.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark.
| | - Nina Nouhravesh
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | | | - Anders Holt
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Lauge Østergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Strange JE, Christensen DM, Sindet‐Pedersen C, Schou M, Falkentoft AC, Østergaard L, Butt JH, Graversen PL, Køber L, Gislason G, Olesen JB, Fosbøl EL. Frailty and Recurrent Hospitalization After Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2023; 12:e029264. [PMID: 37042264 PMCID: PMC10227237 DOI: 10.1161/jaha.122.029264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/07/2023] [Indexed: 04/13/2023]
Abstract
Background For frail patients with limited life expectancy, time in hospital following transcatheter aortic valve replacement is an important measure of quality of life; however, data remain scarce. Thus, we aimed to investigate frailty and its relation to time in hospital during the first year after transcatheter aortic valve replacement. Methods and Results From 2008 to 2020, all Danish patients who underwent transcatheter aortic valve replacement and were alive at discharge were included. Using the validated Hospital Frailty Risk Score, patients were categorized in the low, intermediate, and high frailty groups. Time in hospital and mortality up to 1 year are reported according to frailty groups. In total, 3437 (57.6%), 2277 (38.1%), and 257 (4.3%) were categorized in the low, intermediate, and high frailty groups, respectively. Median age was ≈81 years. Female sex and comorbidity burden were incrementally higher across frailty groups (low frailty: heart failure, 24.1%; stroke, 7.2%; and chronic kidney disease, 4.5%; versus high frailty: heart failure, 42.8%; stroke, 34.2%; and chronic kidney disease, 29.2%). In the low frailty group, 50.5% survived 1 year without a hospital admission, 10.8% were hospitalized >15 days, and 5.8% of patients died. By contrast, 26.1% of patients in the high frailty group survived 1 year without a hospital admission, 26.4% were hospitalized >15 days, and 15.6% died within 1 year. Differences persisted in models adjusted for sex, age, frailty, and comorbidity burden (excluding overlapping comorbidities). Conclusions Among patients undergoing transcatheter aortic valve replacement, frailty is strongly associated with time in hospital and mortality. Prevention strategies for frail patients to reduce hospitalization burden could be beneficial.
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Affiliation(s)
- Jarl Emanuel Strange
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
- Department of CardiologyCopenhagen University Hospital Herlev and GentofteHellerupDenmark
| | | | | | - Morten Schou
- Department of CardiologyCopenhagen University Hospital Herlev and GentofteHellerupDenmark
| | | | - Lauge Østergaard
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Jawad Haider Butt
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Peter Laursen Graversen
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Lars Køber
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Gunnar Gislason
- Department of CardiologyCopenhagen University Hospital Herlev and GentofteHellerupDenmark
- The Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and SciencesUniversity of CopenhagenCopenhagenDenmark
- The National Institute of Public HealthUniversity of Southern DenmarkCopenhagenDenmark
| | - Jonas Bjerring Olesen
- Department of CardiologyCopenhagen University Hospital Herlev and GentofteHellerupDenmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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