NCDR-Derived Risk Model to Predict Inhospital Stroke After TAVR

The first risk model to predict inhospital stroke after transcatheter aortic valve replacement (TAVR) has been developed using data from the STS/ACC TVT Registry. The analysis also provides a benchmark for the rate and relevant patient factors for inhospital stroke post TAVR. The study was published in The Annals of Thoracic Surgery.

Vinod H. Thourani, MD, FACC, et al., identified 97,600 patients who underwent TAVR procedures at 521 sites from July 2014 to June 2017. Association between baseline covariates and in-hospital stroke was estimated by logistic regression. Discrimination was evaluated by C-statistic. Calibration was tested internally via cross-validation. Hierarchical modeling was used to estimate risk-adjusted site-specific performance. The median age of the patients was 82 years and 46 percent were women; 18.4 percent had a prior TIA or stroke. TAVR was elective in 90.9 percent, and the transfemoral approach was used in 89.8 percent. The rate of inhospital stroke was 1.9 percent.

Covariates associated with stroke (odds ratio) included transapical access (1.44); access excluding transapical and transfemoral (1.77); prior stroke (1.57); prior transient ischemic attack (1.50); preprocedural shock, inotropes or mechanical assist device (1.48); smoking (1.28); porcelain aorta (1.23); peripheral arterial disease (PAD) (1.21); age per 5 years (1.11); glomerular rate per 5 mL/min (0.97); body surface area per m2 (0.55 male; 0.43 female); prior aortic valve (0.78); and nonaortic valvular (0.42) procedures. Significant predictors included alternative access, prior stroke or TIA, procedural acuity, smoking, porcelain aorta, PAD, and advanced age.

Site-specific variation was assessed using the model, revealing that 1.9 percent of sites had significantly higher odds ratios for inhospital stroke compared with their peers. The authors write, “When viewed in concert with the overall stroke rate of 1.9 percent for our study population, this finding is very encouraging, especially given that TAVR is still an evolving technology. The low rate of stroke in the current series and contemporary analyses is most likely multifactorial and includes newer and lower profile devices, increased operator experience, and lower-risk patients.”

They conclude that this “model serves as a valuable resource for patient counseling, clinical decision making, quality improvement, and the development and implementation of risk-reduction strategies.”

Keywords: STS/ACC TVT Registry, National Cardiovascular Data Registries, Aged, 80 and over, Ischemic Attack, Transient, Transcatheter Aortic Valve Replacement, Odds Ratio, Aortic Valve, Dental Porcelain, Logistic Models, Peripheral Arterial Disease, Thoracic Surgery, Benchmarking, Quality Improvement, Calibration, Body Surface Area, Stroke, Registries, Aorta, Risk Reduction Behavior, Counseling, Smoking

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