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Balloon Aortic Valvuloplasty as Bridge to TAVR
Study Questions:
What are the incidence, predictors, and outcomes of using balloon aortic valvuloplasty (BAV) as a bridge to transcatheter aortic valve replacement (TAVR)?
Methods:
Data were analyzed from the national readmission database from 2015-2016. Patients who underwent BAV were identified, and predictors and timing of subsequent TAVR were assessed. In-hospital outcomes were compared between those who received subsequent TAVR following BAV and those who underwent TAVR without BAV in the original 2015 to 2016 National Readmission Database dataset.
Results:
Among the 3,691 included patients 1,426 (38.6%) had subsequent TAVR. Timing of TAVR was pre-discharge in 7.4%, within 30 days in 35%, between 31 and 90 days in 47%, between 91 and 180 days in 14%, and >180 days in 4%. Negative predictors of subsequent TAVR included prior defibrillator (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.36-0.85), dementia (OR, 0.60; 95% CI, 0.46-0.79), malnutrition (OR, 0.64; 95% CI, 0.45-0.90), and malignancy (OR, 0.62; 95% CI, 0.47-0.82). In propensity-score matched cohorts of patients who underwent direct TAVR versus those with prior BAV, in-hospital mortality during TAVR admission was similar (3.7% vs. 3.5%; p = 0.91). Major complications, length of stay, and discharge disposition were also comparable. However, cost of the hospitalization was higher in the direct TAVR group.
Conclusions:
About 40% of BAV patients undergo subsequent TAVR mostly within 90 days. In-hospital outcomes of TAVR in these patients were comparable with propensity-score matched patients who underwent TAVR without prior BAV. Further investigations are needed to define the role of BAV in contemporary practice.
Perspective:
With the expanding role of TAVR, the current study evaluates an important question regarding the role of BAV among patients who have severe comorbidity and are unable to undergo direct TAVR for severe aortic stenosis. Authors used the national readmission database and noted that approximately 40% of patients who undergo BAV eventually undergo TAVR with the majority receiving definitive treatment by 3 months. Although it is reported that in-hospital outcomes between those who received BAV versus those who did not prior to TAVR are similar, clinical applicability of the findings should be tempered in the setting of significant selection bias (60% of patients who did not receive TAVR were not included in the comparison). Role and timing of BAV for patients with severe aortic stenosis who are not candidates for direct TAVR should remain an individualized decision for each patient.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Sleep Apnea
Keywords: Aortic Valve Stenosis, Balloon Valvuloplasty, Comorbidity, Defibrillators, Dementia, Heart Valve Diseases, Heart Valve Prosthesis, Hospital Mortality, Length of Stay, Malnutrition, Neoplasms, Patient Discharge, Patient Readmission, Transcatheter Aortic Valve Replacement
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