End of life after transcatheter aortic valve implantation

Abstract

Abstract Background Survival after transcatheter aortic valve implantation (TAVI) has drastically improved over time. Thus, patients may be more susceptible to experience multimorbidity and non-cardiovascular hospitalizations in their final years of life; however, the extent of which comorbidities impact end of life after TAVI is unknown. Purpose To describe end of life after TAVI in terms of the burden and causes of hospitalization compared with non-TAVI controls from the general population. Methods All Danish patients who underwent TAVI during 2008–2021 were identified at date of death. Patients who died within one year from TAVI were excluded. Matching was performed on sex, age at death, and calendar year of death in a 1:10 ratio. Patient characteristics at time of death were reported. Cumulative time in hospital was calculated and compared for the TAVI group and matched controls. Further, the cause for all inpatient hospitalizations were categorized as heart failure, cardiovascular (excluding heart failure), non-cardiovascular, and symptoms (e.g., dyspnea, vomiting) according to the primary discharge code. Results After exclusion, 2,041 deaths among patients with TAVI (median time from TAVI to death: 1,352 days [25th-75th percentile: 841–1,980]) were matched to 20,410 deaths among controls (standardized mean differences < 0.1 for all matching variables). Due to matching, age was 86 years, and 54.7% were males in both groups. However, frailty was higher in the TAVI group (frail TAVI group: 86.5% vs. controls: 76%). Cardiovascular and non-cardiovascular comorbidity burden was higher in the TAVI group (e.g., heart failure: 57.6% vs. 18.4%; chronic obstructive pulmonary disease: 27.9% vs. 18.8%; chronic kidney disease: 25.7% vs. 12.9%). However, history of cancer was lower in the TAVI group (21.7% vs. 26.3%). Time in hospital in the last year of life was higher in the TAVI group: 27.2% were hospitalized >28 days and 11.5% were never hospitalized compared with 17.1% and 22.7% for controls, respectively (Figure 1). In both groups, non-cardiovascular hospitalizations were most common towards end of life. Indeed, 70.5% of hospitalizations during the last year of life for TAVI patients were due to non-cardiovascular causes. Moreover, in both groups, non-cardiovascular hospitalizations became more frequent closer to time of death (Figure 2). However, heart failure hospitalizations were more common in the TAVI group compared with controls. Conclusion End of life for TAVI patients was characterized by substantial multimorbidity and hospitalizations are frequent. Although heart failure hospitalizations were more common for TAVI patients than their matched controls, non-cardiovascular hospitalizations were more frequent in both groups. This highlights the need for a multidisciplinary approach to improve quality of life towards end of life after TAVI.Figure 1