Risk and Timing of Noncardiac Surgery After TAVI
- In a relatively large cohort of TAVI patients, the risk of a 30-day adverse clinical event after noncardiac surgery was approximately 20%, with a 30-day mortality rate of nearly 10%.
- Baseline patient characteristics and timing, urgency, and surgical risk category were not associated with composite outcomes.
- Suboptimal device performance, such as paravalvular regurgitation and prosthesis–patient mismatch, was associated with an increased risk of adverse outcomes.
What are the perioperative adverse events associated with noncardiac surgery following transcatheter aortic valve implantation (TAVI), and how do these vary by timing of surgery, type of surgery, and TAVI valve performance?
Consecutive patients undergoing TAVI between 2012–2020 were enrolled prospectively at Bern University Hospital, a part of the nationwide Swiss TAVI registry. Standard transthoracic echocardiographic measurements were performed following TAVI and prior to discharge. These included degree of paravalvular regurgitation (PVR) and prosthesis–patient mismatch (PPM) based on prosthetic effective orifice area indexed to body surface area (severe ≤0.65 cm2/m2 or moderate 0.55–0.70 cm2/m2). The study cohort consisted of all patients from the TAVI registry who underwent noncardiac surgery at some point following their aortic valve intervention. The timing (i.e., interval between TAVI and subsequent surgery), clinical urgency, and risk category of the surgical procedure were assessed. The primary outcome measure was a composite of all-cause death, stroke, myocardial infarction (MI), and major or life-threatening bleeding at 30 days after noncardiac surgery.
A total of 2,238 consecutive patients underwent TAVI, of whom 300 patients underwent noncardiac surgery. This was elective for 160 patients and urgent/emergent for 140 patients. 48% were women and mean age was 81.8 ± 6.6 years. 21% of patients had noncardiac surgery within 30 days of TAVI, 25% between 31–180 days, 23% between 181–365 days, and 31% >1 year (out to nearly 5 years). Noncardiac procedures were stratified into low-risk (7%), intermediate-risk (63.3%) and high-risk (29.7%), according to ESC/ESA-NCS (European Society of Cardiology/European Society of Anesthesiology-noncardiac surgery) risk categories. Neurological and orthopedic surgery (32.7%) were most common.
Fifty-eight patients (19.7%; 95% confidence interval [CI], 15.6-24.7%) had the composite endpoint within 30 days of noncardiac surgery. All-cause death occurred in 28 patients (9.6%; 95% CI, 6.7-13.5%), stroke in three patients (1.1%; 95% CI, 0.3-3.2%), MI in one patient (0.4%; 95% CI, 0.1-2.6%), and major or life-threatening bleeding in 33 patients (11.3%; 95% CI, 8.2-15.6%).
There were no significant differences in baseline characteristics between those with (52 patients) and without (248 patients) adverse events after noncardiac surgery. Likewise, the timing, urgency, and surgical risk category were not associated with increased risk of the composite endpoint. However, patients who experienced a composite endpoint within 30 days of surgery had a smaller mean indexed effective orifice area (0.86 ± 0.24 cm2/m2) than those who did not (0.95 ± 0.28 cm2/m2, p = 0.048). Furthermore, these patients were more likely to have moderate or severe PPM (54.2% vs. 23.8%, p = 0.001) or PVR (6.9% vs. 0.8%, p = 0.003), as compared to those without the composite endpoint. On multivariable analysis, these variables were independently associated with the 30-day composite endpoint.
The authors concluded: 1) Noncardiac surgery may be performed early after successful TAVI with relatively good outcomes (~10% 30-day mortality and 20% composite adverse event). 2) Patient characteristics and timing, urgency, and category of noncardiac surgery were not associated with 30-day composite outcome of death, stroke, MI, or bleeding. 3) Suboptimal device performance, such as PPM and PVR, were independently associated with increased risk of 30-day adverse clinical event.
This relatively large registry-based cohort study is the first to assess outcomes after noncardiac surgery in patients who have undergone TAVI. The substantial perioperative risk associated with severe aortic stenosis is well known and often considered prohibitive. While retrospective studies suggest that surgical aortic valve replacement can decrease these risks, it may not be an option for all patients. This study indicates, for the first time, that TAVI can also reduce perioperative risk. Moreover, it suggests that the risk of adverse outcome depends only on the quality of the aortic intervention and not on patient characteristics or the nature or timing of the surgical procedure.
While the data support what is already a widely held belief, it is important to acknowledge several limitations of the study. First, there is inherent selection bias, as the cohort included only patients who were offered surgery in the first place. Moreover, echocardiographic assessment of the TAVI was performed only at the time of intervention and not immediately prior to noncardiac surgery.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Aortic Valve Insufficiency, Aortic Valve Stenosis, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, General Surgery, Geriatrics, Heart Valve Diseases, Hemorrhage, Myocardial Infarction, Orthopedic Procedures, Outcome Assessment, Health Care, Patient Discharge, Prostheses and Implants, Risk, Stroke, Transcatheter Aortic Valve Replacement
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