Abstract 14989: Failure to Rescue After Transcatheter Aortic Valve Replacement: Does Experience Matter?

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Lise Tchouta ◽  
Hechuan Hou ◽  
Karen Kim ◽  
Mike Thompson
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Hospital Mortality ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
High Volume ◽  
Failure To Rescue ◽  
Transcatheter Aortic Valve ◽  
Significant Difference ◽  
Procedural Complications

Introduction: Volume-outcome relationships are well defined in transcatheter aortic valve replacement (TAVR), but little is known about how hospital experience in aortic valve replacement (AVR) informs processes of care to rescue patients once a complication occurs after TAVR. Hypothesis: Increasing AVR experience improves post-TAVR rates of failure to rescue (FTR) - defined as in-hospital mortality after major treatable post-procedural complications. Methods: Statewide Inpatient Databases from seven diverse states were queried from 2011 to 2017 for patients who underwent TAVR. Hospitals were stratified as low vs high-volume by mean annualized SAVR and TAVR volume using the median as cutoff: SAVR = 43 cases/year, TAVR = 28 cases/year. Crude rates of complications, in-hospital mortality, and FTR were estimated for the overall sample and stratified by SAVR and TAVR volume (low vs high). Logistic regression was used to estimate the adjusted odds ratio of SAVR and TAVR volume, independently, on the outcomes above, adjusting for patient demographics and comorbid conditions. Results: A total of 42,025 TAVR patients were identified and categorized as low (N = 2,946) or high-volume (N = 39,079) SAVR centers, and low (N = 7,183) or high-volume (N = 34,842) TAVR centers. Within the high-volume SAVR centers, 84.8% were also high-volume TAVR centers. Low SAVR or TAVR volume was associated with a marginal increase in the risk of developing complications after TAVR (OR 1.26; P < 0.001 and OR 1.14; P < 0.001) as show in Table 1. There was no statistically significant difference in risk-adjusted in-hospital mortality rates (OR 1.10; P = 0.499 and OR 1.10; P = 0.273) or FTR rates (OR 0.97; P = 0.816 and OR 1.03; P = 0.732) after TAVR between low- and high-volume SAVR or TAVR centers, respectively. Conclusion: Undergoing TAVR at a high-volume SAVR or TAVR center was associated with lower rates of complications, but volume was not an independent predictor of in-hospital mortality or FTR.

Abstract 17027: Racial Disparities in Transcatheter Aortic Valve Replacement Access: Geographic Analysis Suggesting Disparate Access to Care

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Nidal Ganim ◽  
Dominique J Monlezun ◽  
Enrique D Garcia-Sayan ◽  
Prakash Balan
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Racial Disparities ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Private Insurance ◽  
High Volume ◽  
Racial Minorities ◽  
Transcatheter Aortic Valve ◽  
Excess Costs

Background: Transcatheter aortic valve replacement (TAVR) has ample randomized trial evidence that it can reduce mortality and cost for patients with aortic stenosis. Yet racial disparities in procedure access are poorly understood. Methods: This case-control prospectively enrolled TAVR subjects at a single high-volume quaternary academic medical center in Houston, Texas, USA, from 11/8/11-3/28/18. Neural network machine learning-supported binomial probability testing was conducted comparing the Houston population versus the center’s TAVR rates by race, with mortality and cost extrapolations. The IOM definition of health inequities was applied using the rank and replace method for counterfactual comparison (matching subjects by insurance and Society of Thoracic Surgery [STS] risk score for TAVR eligibility). Results: Compared to the Houston population, TAVR subjects (N=1641) were significantly more likely to be Caucasians (51.93% vs 77.26%), and less likely to be African Americans (14.80% vs 6.02%), Hispanics (23.63% vs 15.02%), or other races (9.50% vs 1.70%), all p<0.001. Among TAVR subjects with private insurance, the large majority were Caucasian (832, 85.60%), with the minority being African American (34, 3.50%), Hispanic (96, 9.88%), and other (10, 37.04%) (private insurance by Caucasian versus non-Caucasian, p<0.001). Based on TAVR mortality and cost savings in the PARNTER trial, access disparities for racial minorities over 5 years may result in 858 excess deaths, $130,000 per patient excess costs, and $111.5 million excess costs per the overall sample of eligible presenting Houston subjects. The predicted versus actual racial distribution of TAVR for each minority group matched to Caucasians by insurance and STS score was significantly greater than the actual (each group comparison to Caucasians, p<0.001). Conclusion: Multi-year data from our high-volume center suggest Houston racial minorities are less likely to undergo TAVR, potentially translating into a growing number of preventable excess early deaths and costs as disease incidence increases. Additional studies are underway to determine and reduce the degree of preventable race-related disparities independent of known access predictors.

Abstract 15741: Long Term Survival Following Transcatheter Aortic Valve Replacement: Results From a Single US High Volume Center

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Ricardo O Escarcega ◽  
Rebecca Torguson ◽  
Marco A Magalhaes ◽  
Nevin C Baker ◽  
Sa’ar Minha ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Term Survival ◽  
Transcatheter Aortic Valve ◽  
Significant Difference ◽  
Long Term Mortality

Introduction: Mortality following Transcatheter aortic valve replacement (TAVR) has been reported up to 5 years. However, mortality after 5 years remains unclear. Hypothesis: We aim to determine the mortality in patients undergoing TAVR >5 years follow up. Methods: From our institution’s prospectively collected TAVR database we analyzed all patients undergoing TAVR to a maximum follow up of 8 years. We divided our population into transapical TAVR (TA-TAVR) and transfemoral TAVR (TF-TAVR) groups. A Kaplan-Meier survival analysis was conducted. Results: A total of 511 patients who underwent TAVR were included in the analysis. Patients undergoing TA-TAVR had higher rates of peripheral vascular disease compared with TF-TAVR (56% vs 29%, p<0.001) and Society of Thoracic Surgeons Score (10.9 ± 4 vs 9.2 ± 4, p<0.001). TA-TAVR was associated with higher mortality at 1 year (32% vs 21%, p=0.01). However, there was no significant difference in very-long term mortality of patients undergoing TA-TAVR vs TF-TAVR (Figure). Conclusions: Long-term mortality following TAVR surpasses 50%. While in the first 2 years TA-TAVR is associated with higher mortality rates after three years the survival rates are similar in both approaches.

Bleeding Complications Drive In-Hospital Mortality of Patients with Atrial Fibrillation after Transcatheter Aortic Valve Replacement

2020 ◽  
Vol 120 (11) ◽  
pp. 1580-1586 ◽  
Author(s):  
Achim Lother ◽  
Klaus Kaier ◽  
Ingo Ahrens ◽  
Wolfgang Bothe ◽  
Dennis Wolf ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Factor ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Hospital Mortality ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Bleeding Complications ◽  
Hospital Outcome ◽  
Transcatheter Aortic Valve

Abstract Background Atrial fibrillation (AF) is a risk factor for poor postoperative outcome after transfemoral transcatheter aortic valve replacement (TF-TAVR). The present study analyses the outcomes after TF-TAVR in patients with or without AF and identifies independent predictors for in-hospital mortality in clinical practice. Methods and Results Among all 57,050 patients undergoing isolated TF-TAVR between 2008 and 2016 in Germany, 44.2% of patients (n = 25,309) had AF. Patients with AF were at higher risk for unfavorable in-hospital outcome after TAVR. Including all baseline characteristics for a risk-adjusted comparison, AF was an independent risk factor for in-hospital mortality after TAVR. Among patients with AF, EuroSCORE, New York Heart Association classification class, or renal disease had only moderate effects on mortality, while the occurrence of postprocedural stroke or moderate to major bleeding substantially increased in-hospital mortality (odds ratio [OR] 3.35, 95% confidence interval [CI] 2.61–4.30, p < 0.001 and OR 3.12, 95% CI 2.68–3.62, p < 0.001). However, the strongest independent predictor for in-hospital mortality among patients with AF was severe bleeding (OR 18.00, 95% CI 15.22–21.30, p < 0.001). Conclusion The present study demonstrates that the incidence of bleeding defines the in-hospital outcome of patients with AF after TF-TAVR. Thus, the periprocedural phase demands particular care in bleeding prevention.

scholarly journals Infective Endocarditis After Surgical and Transcatheter Aortic Valve Replacement: A State of the Art Review

2020 ◽  
Vol 9 (16) ◽  
Author(s):  
Sophia L. Alexis ◽  
Aaqib H. Malik ◽  
Isaac George ◽  
Rebecca T. Hahn ◽  
Omar K. Khalique ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Prosthetic Valve Endocarditis ◽  
Paravalvular Leak ◽  
Surgical Aortic Valve Replacement ◽  
Entry Site ◽  
Transcatheter Aortic Valve ◽  
Significant Difference

Abstract Prosthetic valve endocarditis (PVE) after surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) carries significant morbidity/mortality. Our review aims to compare incidence, predisposing factors, microbiology, diagnosis, management, and outcomes of PVE in surgical aortic valve replacement/TAVR patients. We searched PubMed and Embase to identify published studies from January 1, 2015 to March 13, 2020. Key words were indexed for original reports, clinical studies, and reviews. Reports were evaluated by 2 authors against a priori inclusion/exclusion criteria. Studies were included if they reported incidence and outcomes related to surgical aortic valve replacement/TAVR PVE and excluded if they were published pre‐2015 or included a small population. We followed the Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines for all stages of the design and implementation. Study quality was based on the Newcastle‐Ottawa Scale. Thirty‐three studies with 311 to 41 025 patients contained relevant information. The majority found no significant difference in incidence of surgical aortic valve replacement/TAVR PVE (reported as 0.3%–1.2% per patient‐year versus 0.6%–3.4%), but there were key differences in pathogenesis. TAVR has a specific set of infection risks related to entry site, procedure, and device, including nonstandardized protocols for infection control, valve crimping injury, paravalvular leak, neo‐leaflet stress, intact/calcified native leaflets, and intracardiac hardware. With the expansion of TAVR to lower risk and younger patients, a better understanding of pathogenesis, patient presentation, and guideline‐directed treatment is paramount. When operative intervention is necessary, mortality remains high at 20% to 30%. Unique TAVR infection risks present opportunities for PVE prevention, therefore, further investigation is imperative.

Modifiable Predictors of In-Hospital Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

2018 ◽  
Vol 356 (2) ◽  
pp. 135-140 ◽  
Author(s):  
Oluwaseun A. Akinseye ◽  
Muhammad Shahreyar ◽  
Chioma C. Nwagbara ◽  
Mannu Nayyar ◽  
Salem A. Salem ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Hospital Mortality ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Transcatheter Aortic Valve

scholarly journals Incidence, Predictor, and Clinical Outcomes of Multiple Resheathing With Self‐Expanding Valves During Transcatheter Aortic Valve Replacement

2021 ◽  
Author(s):  
Fernando L. M. Bernardi ◽  
Josep Rodés‐Cabau ◽  
Gabriela Tirado‐Conte ◽  
Ignacio J. Amat Santos ◽  
Claudia Plachtzik ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Severe Aortic Regurgitation ◽  
Transcatheter Aortic Valve ◽  
Device Embolization ◽  
Procedural Complications ◽  
The Impact ◽  
Mortality Hazard Ratio

Background No study has evaluated the impact of the additional manipulation demanded by multiple resheathing (MR) in patients undergoing transcatheter aortic valve replacement with repositionable self‐expanding valves. Methods and Results This study included a real‐world, multicenter registry involving 16 centers from Canada, Germany, Latin America, and Spain. All consecutive patients who underwent transcatheter aortic valve replacement with the Evolut R, Evolut PRO, and Portico valves were included. Patients were divided according to the number of resheathing: no resheathing, single resheathing (SR), and MR. The primary end point was device success. Secondary outcomes included procedural complications, early safety events, and 1‐year mortality. In 1026 patients, the proportion who required SR and MR was 23.9% and 9.3%, respectively. MR was predicted by the use of Portico and moderate/severe aortic regurgitation at baseline (both with P <0.01). Patients undergoing MR had less device success (no resheathing=89.9%, SR=89.8%, and MR=80%; P =0.01), driven by more need for a second prosthesis and device embolization. At 30 days, there were no differences in safety events. At 1 year, more deaths occurred with MR (no resheathing=10.5%, SR=8.0%, and MR=18.8%; P =0.014). After adjusting for baseline differences and center experience by annual volume, MR associated with less device success (odds ratio, 0.42; P =0.003) and increased 1‐year mortality (hazard ratio, 2.06; P =0.01). When including only the Evolut R/PRO cases (N=837), MR continued to have less device success ( P <0.001) and a trend toward increased mortality ( P =0.05). Conclusions Repositioning a self‐expanding valve is used in a third of patients, being multiple in ≈10%. MR, but not SR, was associated with more device failure and higher 1‐year mortality, regardless of the type of valve implanted.

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