Outcomes After Urgent/Emergent TAVR

Study Questions:

What are the outcomes and independent predictors of mortality among patients undergoing urgent/emergent transcatheter aortic valve replacement (TAVR)?

Methods:

The investigators used the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) transcatheter valve therapy (TVT) Registry linked with Centers for Medicare and Medicaid Services claims to identify patients who underwent urgent/emergent versus elective TAVR between November 2011 and June 2016. Outcomes assessed were device success rate, in-hospital major adverse events, and 30-day and 1-year mortality. Independent predictors of mortality after urgent/emergent TAVR were examined. The authors used the TVT Registry in-hospital mortality prediction model (c-statistic, 0.66; 95% confidence interval [CI], 0.62-0.69]) to calculate observed/expected ratios for in-hospital mortality after urgent/emergent versus elective TAVR).

Results:

Of 40,042 patients who underwent TAVR, 3,952 (9.9%) were urgent/emergent (median STS predicted risk of mortality [PROM] score 11.8 [7.6, 17.9]). Device success rate was statistically lower, but not clinically different after urgent/emergent versus elective TAVR (92.6% vs. 93.7%, p = 0.007). Rates of major/life-threatening bleeding, major vascular complications, myocardial infarction, stroke, new permanent pacemaker placement, conversion to surgical AVR, and paravalvular regurgitation were similar between the two groups. Compared with elective TAVR, patients undergoing urgent/emergent TAVR had higher rates of acute kidney injury/new dialysis (8.2% vs. 4.2%, p < 0.001), 30-day mortality (8.7% vs. 4.3%, adjusted hazard ratio [HR], 1.28; 95% CI, 1.10-1.48), and 1-year mortality (29.1% vs 17.5%, adjusted HR, 1.20; 95% CI, 1.10-1.31). In patients undergoing urgent/emergent TAVR, nonfemoral access and cardiopulmonary bypass were associated with increased risk, whereas use of a balloon-expandable valve was associated with decreased risk of 30-day and 1-year mortality.

Conclusions:

The authors concluded that urgent/emergent TAVR is feasible with acceptable outcomes and may be a reasonable option in a selected group of patients with severe aortic stenosis.

Perspective:

This study reports that despite patients undergoing urgent/emergent TAVR having higher burden of comorbidities and STS PROM score, acute device success was high and not clinically different compared with elective TAVR. Furthermore, in patients undergoing urgent/emergent TAVR, oxygen-dependent lung disease, immunocompromised status, pre-existing atrial fibrillation/flutter, higher baseline creatinine, concomitant mitral stenosis, nonfemoral access, and cardiopulmonary bypass were associated with increased risk, whereas use of a balloon-expandable valve was associated with decreased risk of 1-year mortality. It seems that urgent/emergent TAVR may be a reasonable option in a selected group of patients with severe aortic stenosis. However, additional studies are needed to identify patients who may benefit from urgent/emergent TAVR, and to compare outcomes of emergent TAVR versus emergent balloon aortic valvuloplasty followed by elective TAVR (staged procedure).

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: ACC18, ACC Annual Scientific Session, Acute Kidney Injury, Aortic Valve Stenosis, Geriatrics, Heart Failure, Heart Valve Diseases, Hemorrhage, Hospital Mortality, Myocardial Infarction, Outcome Assessment (Health Care), Pacemaker, Artificial, Renal Dialysis, Stroke, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement


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