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Operator Experience and Outcomes in TAVR
Study Questions:
What is the impact of individual operator experience on transfemoral transcatheter aortic valve replacement (TAVR) outcomes?
Methods:
The investigators utilized the New York Statewide Planning and Research Cooperative System data of 8,771 transfemoral TAVR procedures performed by 207 operators between 2012 and 2016. Operator volume was defined by number of TAVR procedures performed during 1 year prior to the index procedure. Hierarchical and restrictive cubic spline regression models were used to evaluate the impact of individual operator experience on risk-adjusted in-hospital outcomes. The primary outcome was a composite of in-hospital mortality, stroke, and/or acute myocardial infarction (AMI). Secondary outcomes were the individual components of the primary outcome.
Results:
After adjusting for hospital and physician characteristics, patients undergoing TAVR performed by high-volume physicians (≥80/year) had a significantly lower risk of death, stroke, or AMI (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.37-0.93), when compared to those treated by low-volume physicians (<24/year). Being treated by operators who performed 200 procedures during the prior year was associated with significantly lower risks of post-procedure stroke (OR, 0.41; 95% CI, 0.17-0.97) and composite events (OR, 0.45; 95% CI, 0.26-0.78). This relationship was nonlinear and a sensitivity analysis excluding the first 10, 20, and 30 procedures for each operator mitigated the effect of the initial learning curve.
Conclusions:
The authors concluded that increased TAVR experience of operators is associated with improved risk-adjusted in-hospital outcomes.
Perspective:
This statewide analysis reports a statistically significant and clinically important association between increasing individual operator experience and a risk-adjusted composite outcome of in-hospital mortality, stroke, and/or MI, primarily driven by a reduction in stroke with increasing operator volume. Furthermore, the association with operator volume was most pronounced for the first 20 sequential procedures, after which a more linear and gradual improvement in risk-adjusted outcomes was observed with increasing individual operator volume. These data suggest the importance of a specialized approach to TAVR therapy and the benefit of proctoring and collaboration with experienced TAVR practitioners during the early learning phase.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and ACS, Interventions and Structural Heart Disease
Keywords: Acute Coronary Syndrome, Heart Valve Diseases, Heart Valve Prosthesis, Hospital Mortality, Myocardial Infarction, Outcome Assessment, Health Care, Primary Prevention, Risk, Stroke, Transcatheter Aortic Valve Replacement
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