TAVI at Hospitals With and Without On-Site Cardiac Surgery

Study Questions:

What are the patient characteristics, complications, and outcomes of patients undergoing transcatheter aortic valve implantation (TAVI) between hospitals with and without an on-site cardiac surgery (CS) department?

Methods:

The investigators analyzed data from the official, prospective German Quality Assurance Registry on Aortic Valve Replacement to compare characteristics and in-hospital outcomes of patients undergoing transfemoral TAVI at hospitals with (n = 75) and without CS departments (n = 22). Continuous variables are presented as mean ± standard deviation and compared using the Student’s t-test including Levene’s test for both the unmatched and matched cohorts. Categorical variables are given as frequencies in percent and compared using Pearson’s χ2 test eventually with Yates correction as appropriate, also for both the unmatched and matched cohorts.

Results:

An interdisciplinary Heart Team was established at all centers (internal staff physicians at hospitals with on-site CS; in-house cardiologists and visiting cardiac surgical teams from collaborating hospitals at non-CS hospitals). In 2013 and 2014, 17,919 patients (81.2 ± 6.1 years, 55% females, German aortic valve [GAV] score 2.0 5.6 ± 5.8%, logistic EuroSCORE I 21.1 ± 15.4%) underwent transfemoral TAVI in Germany: 1,332 (7.4%) at hospitals without an on-site CS department. Patients in non-CS hospitals were older (82.1 ± 5.8 vs. 81.1 ± 6.1 years, p < 0.001), with more frequent comorbidities. Predicted mortality risks per GAV score 2.0 (6.1 ± 5.5 vs. 5.5 ± 5.9%, p < 0.001) and log EuroSCORE I (23.2 ± 15.8 vs. 21.0 ± 15.4%, p < 0.001) were higher in patients at non-CS sites. Complications, including strokes (2.6 vs. 2.3%, p = 0.452) and in-hospital mortality (3.8 vs. 4.2%, p = 0.396), were similar in both groups. Matched-pair analysis of 555 patients in each group with identical GAV score confirmed similar rates of intraprocedural complications (9.2 vs. 10.3%, p = 0.543), strokes (3.2% for both groups, p = 1.00), and in-hospital mortality (1.8 vs. 2.9%, p = 0.234).

Conclusions:

The authors concluded that although patients undergoing TAVI at hospitals without an on-site CS department were older and at higher predicted perioperative death risk, major complications and in-hospital mortality were not statistically different.

Perspective:

This observational study reports that procedural outcomes for TAVI with respect to in-hospital complications and mortality were not statistically different between institutions with and without on-site CS departments. Joint decision making and performance of TAVI in the interdisciplinary Heart Team appears to be the key to successful TAVI. These findings need to be confirmed in a randomized study given the small number of patients undergoing TAVI at non-CS hospitals. At this time, based on current guidelines, pending additional data, clinicians should strongly consider doing TAVI at hospitals with on-site CS.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Cardiac Surgical Procedures, Aortic Valve, Heart Valve Diseases, Heart Valve Prosthesis, Hospital Mortality, Intraoperative Complications, Outcome Assessment (Health Care), Risk, Stroke, Transcatheter Aortic Valve Replacement


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