16 Mar Urgent/Emergent TAVR Feasible But Mortality Higher Than When Performed Electively

MedicalResearch.com Interview with:

Dr. Abbott

Dawn Abbott, MD, FACC, FSCAI
Associate Chief, Faculty Development and Academic Advancement
Director, Interventional Cardiology and Structural Fellowship Programs
Associate Professor of Medicine
Warren Alpert Medical School, Brown
Providence, RI 02903 

MedicalResearch.com: What is the background for this study?

Response: Approximately 35,000 transcatheter aortic valve replacement (TAVR) procedures are now performed annually in the United States (US). TAVR is usually performed as an elective procedure in hemodynamically stable patients. Approximately 1 in 5 hospitalizations for severe aortic stenosis (AS) are emergent with acute decompensation. Balloon aortic valvuloplasty (BAV) is a therapeutic option in patients with acute decompensated AS; however, long-term survival after BAV remains poor with a high incidence of valvular re-stenosis. Data on the outcomes of urgent/emergent TAVR as a rescue therapy in patients with acute decompensated severe AS are extremely limited.

MedicalResearch.com: What are the main findings? 

Response: We used the STS/ACC TVT Registry linked to Medicare administrative claims files to compare clinical outcomes of patients who underwent urgent/emergent versus elective TAVR in the US between November 2011 and June 2016.

The main findings of our study are:

(i) acute device success rate of urgent/emergent TAVR was high and clinically not different from that of elective TAVR;

(ii) patients who underwent urgent/emergent TAVR had higher rates of acute kidney injury or new dialysis, which was related to the worse baseline clinical risk profile of these patients compared with those who underwent elective TAVR;

(iii) patients who underwent urgent/emergent TAVR had higher in-hospital, 30-day, and 1-year mortality; however, the observed in-hospital mortality was significantly lower than expected according to a previously developed TVT Registry risk in-hospital mortality prediction model;

(iv) in patients undergoing urgent/emergent TAVR, oxygen-dependent lung disease, immunocompromised status, pre-existing atrial fibrillation/flutter, higher baseline creatinine, concomitant mitral stenosis, non-femoral access, and cardiopulmonary bypass were associated with increased risk, whereas use of a balloon-expandable valve was associated with decreased risk of 1-year mortality. 

MedicalResearch.com: What should readers take away from your report?

Response: Urgent/emergent TAVR is feasible and can be performed with a high success rate. Mortality is higher when TAVR is performed as an urgent/emergent procedure as opposed to an elective procedure. Thus, patients with severe AS should be carefully followed and ideally, TAVR performed as an elective procedure while patients remain hemodynamically stable. Nonetheless, the observed in-hospital mortality after urgent/emergent TAVR is significantly lower than expected, suggesting that urgent/emergent TAVR may be a reasonable option in a selected group of patients with acute decompensated severe aortic stenosis.

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: Future studies are needed to identify patients who will (and will not) benefit from urgent/emergent TAVR, and to prospectively compare outcomes of emergent TAVR vs. emergent BAV followed by elective TAVR. 

Disclosures: Drs. Kolte and Abbott have no conflict of interest to disclose.

Citations:

ACC 2018 abstract:
Outcomes Following Urgent/Emergent Transcatheter Aortic Valve Replacement: Insights from the STS/ACC TVT Registry
Dhaval Kolte, Sahil Khera, Sreekanth Vemulapalli, Dadi David Dai, Stephan Heo, Andrew Michael Goldsweig, Herbert D. Aronow, Ignacio Inglessis, Sammy Elmariah, Barry Sharaf, Paul Gordon and J. Abbott
JACC Volume 71, Issue 11 Supplement, March 2018
DOI: 10.1016/S0735-1097(18)31550-X

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Last Updated on March 16, 2018 by Marie Benz MD FAAD