Urgent/Emergent TAVR Has Acceptable Outcomes Compared With Elective TAVR
Urgent or emergent transcatheter aortic valve replacement (TAVR) was feasible and had acceptable outcomes, according to results of an STS/ACC TVT registry study presented by Dhaval Kolte, MD, PhD, at ACC.18. The results were simultaneously published in JACC: Cardiovascular Interventions.
Using data from the STS/ACC TVT registry for TAVR procedures performed from 2011 to 2016, the study cohort was categorized into urgent/emergent TAVR vs. elective TAVR groups. The primary endpoint was in-hospital, 30-day, and one-year all-cause mortality. Secondary endpoints included device success, acute kidney injury (AKI), major or life-threatening bleeding and multiple cardiovascular outcomes.
Among the 40,042 patients who underwent TAVR, 36,090 (90.1 percent) were elective and 3,952 (9.9 percent) were urgent/emergent. Patients undergoing urgent/emergent TAVR had lower left ventricular ejection fraction (LVEF) and were more likely to have moderate-to-severe valve insufficiency than those undergoing elective TAVR. Significantly more urgent/emergent TAVR patients had planned valve-in-valve TAVR for degenerated previously implanted bioprostheses. Use of mechanical circulatory support, cardiopulmonary bypass and transapical or transaortic access site was more common in urgent/emergent TAVR.
Patients in the urgent/emergent TAVR vs. elective TAVR group had higher intra-procedural mortality (0.96 vs. 0.49 percent) and in-hospital mortality (6.1 vs. 3.0 percent). In-hospital mortality was lower than predicted by the STS/TVT Registry model for both urgent/emergent and elective TAVR. The device success rate was significantly lower with urgent/emergent vs. elective TAVR (92.6 vs. 93.7 percent).
Patients in the urgent/emergent vs. elective TAVR group had significantly higher rates of AKI (7.0 vs. 3.7 percent). Length of stay was significantly longer after urgent/emergent TAVR than elective TAVR. Patients in the urgent/emergent TAVR group were more likely to be discharged to a skilled nursing facility or extended care or rehabilitation unit.
The median follow-up was 338 days for the urgent/emergent TAVR group and 394 days for the elective group. Thirty-day mortality was significantly higher among patients who underwent urgent/emergent vs. elective TAVR (8.7 vs. 4.3 percent). Patients in the urgent/emergent TAVR vs. elective TAVR group also had higher one-year mortality (29.1 vs. 17.5 percent). Factors independently associated with an increased risk of 30-day and 1-year mortality in the urgent/emergent TAVR group included oxygen-dependent lung disease, atrial fibrillation or flutter, use of cardiopulmonary bypass during TAVR, and nonfemoral access site. Use of a balloon-expandable valve was inversely associated with 30-day and one-year mortality.
Acute device success after urgent/emergent TAVR was high and clinically similar with elective TAVR. Mortality rates were higher among patients undergoing urgent/emergent TAVR compared with elective TAVR. The authors concluded that urgent/emergent TAVR is feasible with acceptable outcomes and may be a reasonable option in a select group of patients with severe aortic stenosis.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: ACC18, ACC Annual Scientific Session, Transcatheter Aortic Valve Replacement, Hospital Mortality, Bioprosthesis, Cardiopulmonary Bypass, Skilled Nursing Facilities, Cardiopulmonary Bypass, Skilled Nursing Facilities, Atrial Fibrillation, Factor V, Length of Stay, Oxygen, Follow-Up Studies, Stroke Volume, Aortic Valve Stenosis, Aortic Valve, Heart Valve Diseases, Heart Valve Prosthesis, Registries, Acute Kidney Injury, Lung Diseases
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