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

Abstract

Background: Urgent transcatheter aortic valve implantation (TAVI) is a feasible option for aortic stenosis (AS) patients with decompensated heart failure (HF) and cardiogenic shock (CS) as compared to the more traditional urgent balloon aortic valvuloplasty (BAV).Objectives: We conducted a retrospective analysis to compare risk and cause of readmission in these two high-risk groups.Methods: Nationwide Readmission Database (NRD) 2011-2014 was retrospectively analyzed to identify patients with AS having either urgent TAVI or urgent BAV using appropriate ICD-9 codes. Propensity scores were used to match patients with urgent TAVI as compared to patients with urgent BAV. Statistical analysis was performed using the Stata 15.1 software. Results:We identified a weighted sample of 6,670 patients with urgent BAV and 6,964 patients with urgent TAVI. The all-cause 30-and 90-day readmission was lower in the urgent TAVI group compared to urgent BAV (15.4 vs. 22.5%, (aHR): 0.92 [0.90-0.95] p < .001). 30-day readmission due to CV cause and HF was also lower in the urgent TAVI group (aHR, 0.93: p < .001 and aHR, 0.98: p = .040, respectively). The 30-day gastrointestinal (GI) bleed readmission rate was three times higher in urgent TAVI group (aHR, 3.00:95% CI (1.23-7.33), p = .016), but was not statistically significant at 90-days.Cardiac causes of readmission were the predominant cause of readmission in both groups, but more pronounced in urgent BAV group (60.3 vs. 40.5%, p < .001). Conclusion:Urgent TAVI appears beneficial in patients with AS and decompensated HF or CS driven by roughly 10 and 25% reductions in overall readmissions at 30 and 90 days, and marked reductions in reintervention, although offset partially by higher risk of readmission due to GI bleeding at 30 days.

Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology

“…In addition, urgent BAV showed a higher rate of 30-and 90-day HF readmission compared to TAVI performed in urgency settings. 125,128,129 not available for urgent TAVI, Doppler echocardiography of the ileo-femoral arterial axis and three-dimensional echocardiography can be used for access choice and valve sizing. BAV can be performed as palliative measure when general conditions prohibit any further intervention, and it may be also appropriate in patients with multifactorial causes of acute decompensation and for whom the expected benefit of valve replacement is limited.…”

“…If TAVI is not available, then transferring the patient to a centre with SAVR or TAVI capabilities is an important consideration when performing BAV. In addition, urgent BAV showed a higher rate of 30‐ and 90‐day HF readmission compared to TAVI performed in urgency settings 125,128,129 . If pre‐procedural computed tomography scan is not available for urgent TAVI, Doppler echocardiography of the ileo‐femoral arterial axis and three‐dimensional echocardiography can be used for access choice and valve sizing.…”

‘Acute Heart Failure’: Should We Abandon the Term Altogether?

“…Of particular relevance, severe aortic stenosis has a particularly poor prognosis in the presence of the heart failure syndrome or left ventricular systolic dysfunction. Non-surgical options for the management of aortic stenosis include balloon valvuloplasty and transcatheter aortic valve implantation (TAVI), with retrospective analyses suggesting the risk of re-hospitalisation and subsequent interventions is lower in those undergoing immediate rather than delayed TAVI, even after adjustment for relevant confounders [ 53 ].…”

Optimal management of acute decompensated aortic stenosis

“…In the present study, they utilized the administrative National-Readmission-Database (2011-2014) to compare readmission rates after BAV versus TAVI performed during "non-elective" hospitalizations. 4 In a sample of 13,634 hospitalizations (50% in each arm), urgent TAVI was associated with a lower rate of all-cause readmission at 30-and at 90-day. These results persisted after risk-adjustment and with propensity matching.…”

“…In this issue of the Journal, Bandyopadhyay et al expand on their prior work, which showed similar in‐hospital mortality following urgent BAV and TAVI procedures. In the present study, they utilized the administrative National‐Readmission‐Database (2011–2014) to compare readmission rates after BAV versus TAVI performed during “non‐elective” hospitalizations 4 . In a sample of 13,634 hospitalizations (~50% in each arm), urgent TAVI was associated with a lower rate of all‐cause readmission at 30‐ and at 90‐day.…”