Urgent transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis is associated with increased 30-days mortality: a systematic review and meta-analysis

Abstract

Abstract Funding Acknowledgements None. Introduction In patients with severe symptomatic aortic stenosis (AS), transcatheter aortic valve replacement (TAVR) has emerged as a safe and effective therapeutic option; yet, 20% of these patients' hospitalizations are related to acute decompensation. The vast majority of TAVR procedures conducted across the US are elective procedures on patients who are hemodynamically stable. Despite that, according to recent research, urgent TAVR may be a feasible option for AS patients experiencing acutely decompensated heart failure or cardiogenic shock. Additionally, there is also a gap in the guidelines concerning the interventions in this acute setting, with only a brief recommendation for aortic balloon valvuloplasty as a bridge to TAVR or surgery in decompensated AS. Purpose The aim of this systematic review and meta-analysis is to assess 30-days mortality post-TAVR in patients submitted to an urgent procedure and compare them with the elective TAVR population. Methods We systematically searched three major databases (Medline, Cochrane Central Register of Controlled Trials and Scopus) for studies comparing patients submitted to urgent versus elective TAVR. Primary endpoint of our systematic review and meta-analysis is the 30-days mortality post-procedurally. Only studies provided data about our primary endpoint were considered in this analysis. Secondary endpoints comprised acute kidney injury (AKI), permanent pacemaker implantation (PPM) and stroke during the first 30-days post-TAVR. Risk ratio (RR) was calculated with 95% confidence intervals (CIs) and a random-effects model (Mantel-Haenzel) was used to estimate the pooled RR. Results This systematic review acquired 497 results. After duplicates removal, we screened 454 reports and we read full-text articles of 35 studies. Fourteen studies were included in our analysis. A total of 43,051 patients undergoing TAVR were included in our analysis; 3,607 patients submitted to an urgent TAVR, while the rest 39,444 had an elective procedure. Our analysis showed that patients undergoing urgent TAVR have 244% higher risk for mortality during the first 30-days post-procedurally (RR: 2.44, 95%CI: 1.49, 3.99) (Figure). Data about AKI, PPM and stroke during the first 30-days post-TAVR were available for 10 studies. The risk for AKI appeared to be significantly higher in patients undergone urgent TAVR (RR: 2.68, 95% CI: 1.60, 4.47). No significant differences were observed in stroke incidence (RR: 1.04, 95% CI: 0.89, 1.20) and PPM (RR: 1.08, 95%CI: 0.95, 1.22) during 30-days follow-up. Conclusion Compared to elective procedures, urgent TAVR seems to have increased 30-days mortality and AKI, and comparable PPM and stroke rates. These findings provide valuable insights offering potential updates to current guidelines in this field. Further studies on long-term outcomes and in a larger patient population are needed.