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Incidence and Outcomes of Surgical Bailout During TAVR
Study Questions:
What is the incidence and what are the outcomes of surgical bailout during transcatheter aortic valve replacement (TAVR)?
Methods:
The investigators analyzed data from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry with respect to whether surgical bailout was performed during the index TAVR procedure. A Cox proportional hazards model was used to evaluate 1-year mortality and major adverse cardiovascular events.
Results:
Between November 2011 and September 2015, a total of 47,546 patients underwent TAVR. Surgical bailout during TAVR was performed in 1.17% of the cases (n = 558); the most frequent indications were valve dislodgment (22%), ventricular rupture (19.9%), and aortic valve annular rupture (14.2%). The incidence of surgical bailout significantly decreased over time (first tertile 1.25%, second tertile 1.43%, third tertile 1.04%; p = 0.0088). The 30-day and 1-year incidence of major adverse cardiovascular events (54.6% vs. 7.4% [p < 0.0001] and 63.92% vs. 20.29% [p < 0.0001]) and all-cause mortality (50.00% vs. 4.98% [p < 0.0001] and 59.79% vs. 17.06% [p < 0.0001]) were significantly higher in those who underwent bailout. Independent predictors of surgical bailout included female sex, hemoglobin, left ventricular ejection fraction, nonelective cases, and nonfemoral access. Body surface area was the only independent predictor of survival after surgical bailout.
Conclusions:
The authors concluded that in a large, nationally representative registry, the need for surgical bailout in patients undergoing TAVR is low, and its incidence has decreased over time.
Perspective:
This registry study reports that the need for emergent conversion to open heart surgery, or surgical bailout, during TAVR is low at approximately 1% and furthermore, the incidence of surgical bailout has significantly decreased over time, mirroring a decrease in the use of nonfemoral access during the study period. Of note, the clinical outcomes of patients requiring surgical bailout during TAVR are poor, at >10-fold higher than in those patients not requiring emergent conversion to open heart surgery. Independent predictors of need for surgical bailout included female sex, increasing hemoglobin, increasing left ventricular ejection fraction, nonelective cases, and nonfemoral access. These findings may be used for refinement of procedural planning and optimal patient selection for TAVR.
Keywords: Body Surface Area, Cardiac Surgical Procedures, Heart Valve Diseases, Heart Valve Prosthesis, Hemoglobins, Secondary Prevention, Stroke Volume, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement, Treatment Outcome
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