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On-Site Cardiac Surgery and TAVR Outcomes
Study Questions:
What is the outcome of high-risk and inoperable patients with severe symptomatic aortic stenosis undergoing transfemoral transcatheter aortic valve replacement (TAVR) in hospitals with (iOSCS) versus without institutional on-site cardiac surgery (no-iOSCS)?
Methods:
The investigators evaluated 1,822 consecutive high-risk patients with severe symptomatic aortic stenosis undergoing transfemoral TAVR using the prospective multicenter Austrian TAVI registry. A total of 290 patients (15.9%) underwent TAVR at no-iOSCS centers (no-iOSCS group), whereas the remaining 1,532 patients (84.1%) were treated in iOSCS centers (iOSCS group). Propensity score matching was performed to compare outcomes using the “Across” technique because of its advantages in reducing bias.
Results:
Patients of the no-iOSCS group had a higher perioperative risk defined by the logistic EuroSCORE (20.9% vs. 14.2%; p < 0.001) compared with patients treated in hospitals with iOSCS. Procedural survival was 96.9% in no-iOSCS centers and 98.6% in iOSCS centers (p = 0.034), whereas 30-day survival was 93.1% versus 96.0% (p = 0.039) and 1-year survival was 80.9% versus 86.1% (p = 0.017), respectively. After propensity score matching for confounders, procedural survival was 96.9% versus 98.6% (p = 0.162), 93.1% versus 93.8% (p = 0.719) at 30 days, and 80.9% versus 83.4% (p = 0.402) at 1 year.
Conclusions:
The authors concluded that after propensity score matching, short- and long-term mortality was similar between centers with and without on-site cardiac surgery.
Perspective:
This study reports that patients treated in hospitals without on-site cardiac surgery were older, had a higher prevalence of coronary artery disease or previous percutaneous coronary intervention, and consequently showed a higher procedural risk defined by the logistic EuroSCORE. After adjustment for comorbidities using a propensity score matched analysis, short- and long-term survival rates in both treatment groups were comparable and similar between centers with and without on-site cardiac surgery. Well-coordinated heart teams with regular multidisciplinary rounds for each individual patient were a prerequisite in all TAVR-performing sites in this study, and it is apparent that close cooperation between cardiologists and cardiovascular surgeons within the heart team is critical to guarantee high-quality interventions, optimize outcomes, and minimize the risk of adverse events in TAVR patients.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Heart Valve Diseases, Heart Valve Prosthesis, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Primary Prevention, Risk, Survival Rate, Transcatheter Aortic Valve Replacement
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