Outcomes of urgent versus nonurgent transcatheter aortic valve replacement

Abstract

BackgroundThere is a paucity of data regarding the outcomes of transcatheter valve replacement (TAVR) performed in an urgent clinical setting.MethodsThe Nationwide Inpatient Sample (NIS) database years 2011–2014 was used to identify hospitalizations for TAVR in the urgent setting. Using propensity score matching, we compared patients who underwent TAVR in nonurgent versus urgent settings.ResultsAmong 42,154 hospitalizations in which TAVR was performed, 10,114 (24%) underwent urgent TAVR. There was an uptrend in the rate of urgent TAVR procedures (p = .001). The rates of in‐hospital mortality among this group did not change during the study period (p = .713). Nonurgent TAVR was associated with lower mortality (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.69–0.89, p < .001) compared with urgent TAVR. Nonurgent TAVR was associated with lower incidence of cardiogenic shock (OR = 0.46; 95%CI: 0.40–0.53 p < .001), use of mechanical circulatory support devices (OR = 0.69; 95%CI: 0.59–0.82, p < .001), AKI (OR = 0.60; 95%CI: 0.56–0.64 p < .001), hemodialysis (OR = 0.67; 95%CI: 0.56–0.80 p < .001), major bleeding (OR = 0.94; 95%CI: 0.89–0.99 p = .045) and shorter length of stay (7.08 ± 6.317 vs. 12.39 ± 9.737 days, p < .001). There was no difference in acute stroke (OR = 0.96; 95%CI: 0.81–1.14, p = .636), vascular complications (OR = 1.07; 95%CI: 0.89–1.29, p = .492), and pacemaker insertions (OR = 0.92; 95%CI: 0.84–1.01, p = .067) between both groups. Among those undergoing urgent TAVR, subgroup analysis showed higher mortality in patients ≤80 years (p = .033), women (p < .001), chronic kidney disease (p = .001), heart failure (p < .001), and liver disease (p = .003).ConclusionIn this large nationwide analysis, almost a quarter of TAVR procedures were performed in the urgent settings. Although urgent TAVR was associated with higher mortality and increased complications compared with nonurgent TAVR, the absolute difference in in‐hospital mortality was not remarkably higher. Thus, urgent TAVR can be considered as a reasonable approach when indicated.

Readmission following urgent transcatheter aortic valve implantation versus urgent balloon aortic valvuloplasty in patients with decompensated heart failure or cardiogenic shock

“…Patients who underwent urgent TAVI were sicker with multiple comorbidities. 4 A similar finding was noted in another study where urgent TAVI was performed in patients with cardiogenic shock.…”

Efficacy and Safety of Emergent Transcatheter Aortic Valve Implantation in Patients with Acute Decompensated Aortic Stenosis: Systematic Review and Meta-Analysis

“…A significant difference was noted between emergent and elective TAVI on the mortality at hospitalization (emergent vs selective, HR 2.09, 95% CI [1.39 to 3.14], I 2 = 86.5%, Q test P < 0.001, Figure 4(a) ) and 1 year (HR 1.96, 95% CI [1.55 to 2.49], I 2 = 66.2%, Q test P =0.003, Figure 4(b) ) in the random effect model. Cumulative meta-analysis and sensitivity analysis suggested the research of Elbadawi et al [ 15 ] contributed to heterogeneity in the mortality at hospitalization (Supplemental Figures S2(a ) and S2(b) ). After excluding the study, emergent TAVI was still considered to have higher in-hospital mortality (emergent vs selective, HR 2.48, 95% CI [1.58 to 3.91], I 2 = 52.2%, Q test P =0.063, Supplemental Figure S2(c) ).…”

“…A random effect meta-analysis confirmed a statistically significant difference in opposition to the emergent TAVI from the aspects of AKI (RR 2.48, 95% CI [1.85 to 3.32], I 2 = 87.3%, Q test P < 0.001, Figure 5(a) ). After sensitivity analysis, we found that the study of Elbadawi et al [ 15 ] had an impact on heterogeneity (Supplemental Figure S3(a) ). After removing this study, the trend of effect quantity combined by meta-analysis did not change (Supplemental Figure S3(b) ).…”

Modeling the impact of delaying transcatheter aortic valve replacement for the treatment of aortic stenosis in the era of COVID-19

“…5,6,23,25,26 If the patient underwent urgent or emergent TAVR, then the probability of operative mortality increased to 2.3% (low risk) and 6.1% (intermediate risk). [18][19][20]27,28 COVID-19. The COVID-19 parameters listed in Table 2 were derived from the limited published reports available as of April 15, 2020.…”

“…29,32 Patients who underwent elective TAVR had improved OS compared with those who underwent urgent or emergent TAVR. [18][19][20] As COVID-19 is a new disease emerging in late 2019, there are no longterm follow-up patient data available for reference. To approximate the effect of COVID-19 on OS after TAVR, we used available data on the impact of in-hospital infections, the principle entity of which is pneumonia, after TAVR on 2-year OS based on hazard ratios.…”