Surgical Aortic Valve Replacement Mortality Research Articles

Dynamic prediction modeling of postoperative mortality among patients undergoing surgical aortic valve replacement in a statewide cohort over a 12-year period

ObjectiveClinical prediction models for surgical aortic valve replacement mortality, are valuable decision tools but are often limited in their ability to account for changes in medical practice, patient selection, and the risk of outcomes over time. Recent research has identified methods to update models as new data accrue, but their effect on model performance has not been rigorously tested. MethodsThe study population included 44,546 adults who underwent an isolated surgical aortic valve replacement from January 1, 1999, to December 31, 2018, statewide in Pennsylvania. After chronologically splitting the data into training and validation sets, we compared calibration, discrimination, and accuracy measures amongst a nonupdating model to 2 methods of model updating: calibration regression and the novel dynamic logistic state space model. ResultsThe risk of mortality decreased significantly during the validation period (P < .01) and the nonupdating model demonstrated poor calibration and reduced accuracy over time. Both updating models maintained better calibration (Hosmer-Lemeshow χ2 statistic) than the nonupdating model: nonupdating (156.5), calibration regression (4.9), and dynamic logistic state space model (8.0). Overall accuracy (Brier score) was consistently better across both updating models: dynamic logistic state space model (0.0252), calibration regression (0.0253), and nonupdating (0.0256). Discrimination improved with the dynamic logistic state space model (area under the curve, 0.696) compared with the nonupdating model (area under the curve, 0.685) and calibration regression method (area under the curve, 0.687). ConclusionsDynamic model updating can improve model accuracy, discrimination, and calibration. The decision as to which method to use may depend on which measure is most important in each clinical context. Because competing therapies have emerged for valve replacement models, updating may guide clinical decision making.

Abstract 14677: Therapeutic Outcomes in Concomitant Cardiogenic Shock and Severe Aortic Stenosis: Insights From the National Inpatient Sample

Introduction: Cardiogenic shock (CS) in patients with concomitant severe aortic stenosis (AS) is a critical combination of pathologies that has been associated with a 43% to 77% in-hospital mortality. There is scant data regarding outcomes after medical management (MM), transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in this high risk population. Methods: The National Inpatient Sample was queried from 2011-2019 for relevant ICD-9 and ICD-10 codes to identify patients with AS and CS who underwent MM, TAVR or SAVR. Binary logistic regression was used to adjust outcomes for significantly different baseline characteristics. Results: We identified a weighted sample of 4,663,000 patients with AS, of which 26,101 had a concurrent diagnosis of CS and did not meet exclusion criteria. Medical management was associated with increased mortality compared to treatment with TAVR or SAVR (aOR 2.231, 95% CI 2.032-2.448, p&lt;0.001). SAVR was associated with decreased mortality when compared to TAVR, although the difference was not statistically significant. Patients that underwent intervention, and specifically SAVR, had lower odds of cardiac arrest than patients that underwent medical management (SAVR aOR 0.514, 95% CI 0.386- 0.685, p&lt;0.001, TAVR aOR 1.946, 95% CI 1.461-2.592, p&lt;0.001). Medical management was associated with decreased risk of complete heart block (aOR 0.402, 95% CI 0.341-0.473, p&lt;0.001), length of stay (8.4±9.9 days versus 9.6±8.5 for TAVR and 11.4±9.7 for SAVR, p&lt;0.001) and cost of stay ($151,605±200,268 versus $352,936 ±297,495 for TAVR and $325,485 ±281,422 for SAVR, p&lt;0.001). Conclusions: Patients with concomitant CS and severe AS have increased mortality with MM as compared to patients that undergo TAVR or SAVR, however there is no significant difference between TAVR and SAVR mortality despite SAVR patients generally having a lower incidence of comorbidities. These patients may benefit from AVR as opposed to MM.

Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database

ObjectivesTo date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to...

Laparoscopic colectomy after transcatheter aortic valve implantation in an elderly patient with obstructive descending colon cancer and severe aortic stenosis: a case report

BackgroundThe demand for laparoscopic colectomy is increasing due to greater number of elderly colon cancer patients, and it is important to evaluate existing comorbidities to ensure perioperative safety. Aortic stenosis (AS) is one of the most common heart diseases in the elderly, and elderly cancer patients with severe AS may be considered ineligible for optimal cancer treatment if they cannot endure surgical aortic valve replacement (SAVR). Recently, transcatheter aortic valve implantation (TAVI) has become a valid option in patients who are high risk for SAVR. We herein present the first case of an elderly cancer patient with severe AS who underwent laparoscopic colectomy after TAVI.Case presentationAn 87-year-old woman with a history of multiple cardiovascular diseases was diagnosed with obstructive descending colon cancer and initially underwent colonic stenting. However, as preoperative echocardiography revealed severe AS, she underwent TAVI prior to the colectomy to reduce perioperative risk. TAVI was chosen instead of SAVR due to high SAVR mortality risk, and laparoscopic colectomy was performed 22 days after TAVI. Her postoperative course was uneventful, and she was discharged 14 days later without any deterioration in general condition. No recurrence was observed at more than 1 year, even without adjuvant therapy.ConclusionTAVI facilitated subsequent laparoscopic colectomy in an elderly cancer patient with severe AS. Our case report shows that TAVI may enable further cancer treatment even in patients with severe AS, who may otherwise be considered not suitable for such treatments.

Association of Hospital Surgical Aortic Valve Replacement Quality With 30-Day and 1-Year Mortality After Transcatheter Aortic Valve Replacement

Hospital outcomes for transcatheter aortic valve replacement (TAVR) may be dependent on the quality of evaluation, personnel, and procedural and postprocedural care common to patients undergoing cardiac surgery. We sought to assess whether those hospitals with better patient outcomes for surgical aortic valve replacement (SAVR) subsequently achieved better TAVR outcomes after launching TAVR programs. This national cohort included US patients 65 years and older. The analysis used the Centers for Medicare and Medicaid Services' Medicare Provider and Review data collected between January 1, 2010, and September 29, 2015. Only hospitals performing at least 1 SAVR prior to September 1, 2011, and performing at least 1 TAVR after this date were included in the analysis. Data analysis was completed from June 2018 to August 2018. Isolated aortic valve replacements. Hospital risk-adjusted 30-day mortality for SAVR in the pre-TAVR period was used as a surrogate for SAVR quality. Thirty-day and 1-year TAVR mortality rates were examined after stratification by quartile of baseline hospital risk-adjusted SAVR mortality. A total of 51 924 TAVR procedures were performed in 519 hospitals, of which 19 798 were performed at hospitals in quartile 1 (the lowest risk-adjusted SAVR mortality rate), 7663 were performed in quartile 2, 10 180 were performed in quartile 3, and 14 283 were performed in quartile 4 (the highest risk-adjusted SAVR mortality rate). Observed mortality rates at 30 days consistently increased with increasing baseline hospital SAVR risk-adjusted mortality (quartile 1, 917 patients [4.6%]; quartile 2, 381 [5.0%]; quartile 3, 521 [5.1%]; quartile 4, 800 [5.6%]; P < .001). The same pattern was observed in 1-year mortality (quartile 1, 3359 [17.0%]; quartile 2, 1337 [17.5%]; quartile 3, 1852 [18.2%]; quartile 4, 2652 [18.6%]; P < .001). After multivariable analysis, compared with the lowest quartile of SAVR mortality, undergoing TAVR at a hospital with higher baseline SAVR mortality continued to be associated with higher 30-day mortality (odds ratios: quartile 2, 1.02 [95% CI, 0.87-1.21]; quartile 3, 1.13 [95% CI, 1.02-1.26]; quartile 4, 1.23 [95% CI, 1.07-1.40]; P = .02) and 1-year mortality (hazard ratios: quartile 2, 1.04 [95% CI, 0.92-1.17]; quartile 3, 1.14 [95% CI, 1.02-1.28]; quartile 4, 1.16 [95% CI, 1.05-1.28]; P = .02). Hospitals with higher SAVR mortality rates also had higher short-term and long-term TAVR mortality after initiating TAVR programs. Quality of cardiac surgical care may be associated with a hospital's performance with new structural heart disease programs.

Trends in Isolated Surgical Aortic Valve Replacement According to Hospital-Based Transcatheter Aortic Valve Replacement Volumes

ObjectivesThis study sought to evaluate the trends in isolated surgical aortic valve replacement (SAVR) procedures across hospitals with different transcatheter aortic valve replacement (TAVR) volumes among Medicare beneficiaries. BackgroundThe volume of TAVR has increased in the United States since its approval, now exceeding that of isolated SAVR. MethodsHospitalizations of adults (≥18 years of age) with International Classification of Diseases-9th Revision-Clinical Modification procedure codes for SAVR (35.21 or 35.22) or TAVR (35.05 or 35.06) who were included in the Medicare Provider Analysis and Review database between January 1, 2011, and December 31, 2014, were included. Trends in isolated SAVR patient characteristics, procedural volumes, and outcomes by quartile (Q) of hospital-level TAVR use were assessed over the study period. ResultsA total of 37,705 isolated SAVR procedures were analyzed for the study. The annual volume of isolated SAVR procedures decreased in hospitals performing the largest number of TAVR procedures (Q3: 1,557 in 2011 to 1,391 in 2014; and Q4: 2,607 in 2011 to 1,791 in 2014). Thirty-day and 1-year mortality after SAVR also declined over the study period in hospitals with the largest TAVR volume (annual change rate in mortality for Q3: −16.4%; p < 0.001; Q4: −20.8%; p < 0.001). ConclusionsThe advent of TAVR was associated with a reduction in isolated SAVR volumes, a decrease in comorbidities among patients undergoing SAVR, and corresponding reductions in observed short- and long-term SAVR mortality among hospitals performing the greatest number of TAVRs.

The risk and extent of neurologic events are equivalent for high-risk patients treated with transcatheter or surgical aortic valve replacement

ObjectivesThis study was designed to characterize the incidence of new clinically detectable neurologic events, or any comparative change in indices of higher cognitive function following transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) within the framework of a prospective, randomized clinical trial for high-risk patients. MethodsHigh-risk patients (predicted SAVR mortality 15%) with severe aortic stenosis (n = 750) were randomized 1:1 to TAVR or SAVR and underwent evaluation using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale assessment at each follow-up and any suspected event. Neurologic outcomes were ascertained by a neurologist and further evaluated by Mini-Mental State Examination (MMSE), visual fields testing, gait assessment, hand function, writing evaluation, and drawing assessment. ResultsThe 30-day, 1-year, and 2-year stroke rates were 4.9%, 8.7%, and 10.9%, respectively, for TAVR and 6.2%, 12.5%, and 16.6%, respectively, for SAVR (P = .46, .11, and .05, respectively). All-cause mortality in patients with a major stroke was 83.3% for TAVR and 54.5% for SAVR at 2 years (P = .29). Late major stroke was disproportionately higher (23.8% at 2 years) among patients with poor iliofemoral access randomized to SAVR. Peripheral vascular disease and falls within 6 months predicted early stroke, and severe aortic calcification and high Charlson score (≥5) predicted 1-year stroke post-TAVR. NIHSS and MMSE scores trended higher after SAVR than after TAVR. Lack of dual antiplatelet therapy use during and after TAVR was associated with early stroke. ConclusionsThis study defines an equivalent postprocedural stroke risk, stroke extent, and degree of cognitive change after TAVR or SAVR in a high-risk population, and also defines several predictors of stroke after TAVR.

Changes in Risk Profile and Outcomes of Patients Undergoing Surgical Aortic Valve Replacement From the Pre– to Post–Transcatheter Aortic Valve Replacement Eras

With initiation of transcatheter aortic valve replacement (TAVR) programs, centers may see changes in surgical aortic valve replacement (SAVR) populations and related outcomes because of more high-risk patients undergoing TAVR rather than SAVR. Little data exist on the potential changes in the risk profiles and outcomes of SAVR patients from the pre- to post-TAVR eras. As such, this study sought to evaluate changes in the SAVR population at a tertiary referral center after TAVR program initiation. Using a single-center valve surgical database, annual volume, patient characteristics, operative details, and predicted and observed mortality for patients undergoing isolated SAVR or SAVR + coronary artery bypass grafting (CABG) from 2006 to 2013 were evaluated. Patients were divided into 3 eras: (1) pre-TAVR (January 2006-June 2009), (2) transition (July 2009-March 2011), and (3) TAVR (April 2011-June 2013). The primary analysis compared predicted and observed mortality in pre-TAVR and TAVR eras. From 2006 to 2013, 1,380 SAVR patients were identified, with 505 (36.6%), 330 (23.9%), and 545 (39.5%) patients from the pre-TAVR, transition, and TAVR eras, respectively. SAVR case volume increased from 131 to 256 cases per year (95.4% increase) from the pre-TAVR to the post-TAVR eras. Predicted risk of mortality (PROM) for SAVR patients from the pre-TAVR to TAVR eras by The Society of Thoracic Surgeons (STS)-PROM was stable near 3.8% (p = 0.82). Crude 30-day SAVR mortality trended down from 2.8% in the pre-TAVR era to 1.5% in the post-TAVR era (p = 0.23). Consistent with previous studies, initiation of a TAVR program was associated with increased SAVR volume. Risk profiles for SAVR patients in the TAVR era remained similar by the STS-PROM, indicating generally stable risk among surgical patients after launching a TAVR program. These data suggest that significant changes in the risk profiles of SAVR patients should not be expected with the initiation of a TAVR program. Further research will need to reevaluate these changes once TAVR becomes more widely available.

Urgent Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Stenosis and Acute Heart Failure: Procedural and 30-Day Outcomes

BackgroundTranscatheter aortic valve implantation (TAVI) is recommended for patients with severe symptomatic aortic stenosis (AS) who are at prohibitive/high risk for surgical aortic valve replacement (SAVR). Patients with severe AS may experience acute decompensated heart failure (HF) that is resistant to medical therapy. We report our TAVI experience in treating patients with unstable AS who require urgent intervention for their aortic valve disease. MethodsPatients were restrictively included in the urgent TAVI registry if they were admitted with acute refractory and persistent HF despite medical therapy and had TAVI performed during the same hospital stay. All others were included in the elective TAVI group. ResultsBetween November 2008 and April 2015, 410 consecutive patients underwent TAVI at our centre—27 (6.6%) urgently. Patients operated on urgently were more likely to be frail and carry higher SAVR mortality risk based on The Society of Thoracic Surgeons Predicted Risk of Mortality/logistic EuroSCORE (LES) measures. Pulmonary edema was the most common clinical presentation. Preprocedural assessment used fewer imaging modalities, yet implantation success remained high and reached 96.3% using an additional valve (valve-within-valve) required in 3 patients, with no difference in periprocedural complications according to the Valve Academic Research Consortium-2 definitions. Although 30-day functional capacity was reduced, patients had similar 30-day mortality and major adverse cardiovascular event rates compared with patients who underwent elective TAVI. ConclusionsShort-term outcome after urgent TAVI appears to be reasonable. For patients with severe AS who experience acute decompensated HF that is recalcitrant to optimal medical therapy and who are at high risk with SAVR, urgent TAVI may be a viable treatment strategy. Larger prospective studies and data on long-term outcomes are needed.

Surgical aortic valve replacement outcomes in the transcatheter era

BackgroundThe primary objective of this study was to evaluate the influence of transcatheter aortic valve implantation (TAVI) on the characteristics and outcomes of patients undergoing surgical aortic valve replacement (SAVR) in a single high-volume Canadian center. MethodsBetween January 2003 and December 2013, 1593 patients underwent isolated SAVR at our institution. The study period was divided into 2 distinct cohorts of patients undergoing SAVR: before (n = 529) and after (n = 1064) the first TAVI procedure in May 2007. We compared the risk profiles and clinical outcomes of the 2 cohorts and assessed the multivariate predictors of in-hospital mortality. ResultsThe ratio of isolated SAVR to the total number of cardiac surgery cases per year rose significantly after the introduction of TAVI (7.2% vs 9.1%; P < .0001). There was significantly more diabetes, obesity, recent myocardial infarction, and use of a bioprosthesis among SAVR patients in the post-TAVI era (all P values < .05). In-hospital mortality decreased significantly among SAVR patients following the introduction of TAVI (3.6% vs 1.8%; P = .03). Independent risk factors for in-hospital mortality among the entire study population were SAVR in the pre-TAVI era, baseline creatinine, age, and prosthesis size ≤ 21 mm for the pre-TAVI group only. ConclusionsThe number of isolated SAVR cases increased following the introduction of TAVI. There was a significant reduction in operative mortality of SAVR in the post-TAVI era despite greater severity of several markers of risk. Patient referrals for TAVI should take into consideration the changing risk profiles and improved results of conventional surgery.

The Association of Transcatheter Aortic Valve Replacement Availability and Hospital Aortic Valve Replacement Volume and Mortality in the United States

Whether the introduction of transcatheter aortic valve replacement (TAVR) has affected hospitals' surgical aortic valve replacement (SAVR) and overall aortic valve replacement (AVR) case volumes and outcomes in the United States is unknown. We utilized data from The Society of Thoracic Surgeons (STS) adult cardiac surgery database and the STS/American College of Cardiology (ACC) transcatheter valve therapies registry to examine SAVR and TAVR procedures. Temporal trends in total case volume (SAVR plus TAVR), and observed and risk-adjusted in-hospital mortality rates were assessed among low-risk cases (STS predicted risk of operative mortality < 4%), intermediate-risk cases (4% to 8%), and high-risk cases (> 8%). A contemporary control was provided by non-TAVR centers. From 2008 to 2013, the total annual volume of AVR among 246 TAVR-performing hospitals increased from 19,578 to 33,004, with a 22% growth in SAVR volumes; non-TAVR hospital (n= 555) increases were more modest (16,563 to 19,134; 16% growth). Expanded volumes at TAVR hospitals included increased SAVR use in low- and intermediate-risk cases, and TAVR use in high-risk cases. In parallel, in-hospital mortality for all AVR procedures at TAVR sites declined from 3.4% to 2.9% (observed to expected [O:E] ratio 0.75 to 0.58, p < 0.001); the greatest declines were among intermediate- and high-risk SAVR patients. Owing to reduced SAVR mortality, TAVR centers experienced a significantly greater decline in O:E ratio for high-risk patient in-hospital mortality than non-TAVR centers (TAVR center O:E ratio, 0.81 to 0.61; non-TAVR center O:E ratio, 0.85 to 0.76; p < 0.001). After approval of TAVR for clinical use, a trend toward higher in-hospital mortality rates and O:E ratios for TAVR procedures was observed at new (but not at established) TAVR centers (O:E ratio, 0.41 to 0.67; p= 0.08). Since the introduction of TAVR, the total volume of AVR procedures, including higher overall use of SAVR, at TAVR sites has significantly increased in the United States. Overall, in-hospital survival of patients undergoing treatment for aortic valve stenosis continues to improve.

Comparing outcomes between surgical aortic valve replacement and transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has been introduced for the treatment of high-risk patients with symptomatic aortic stenosis. Surgical aortic valve replacement (SAVR) provides the therapeutic armamentarium for all complex valvular pathologies and is the established gold standard. TAVI has initially been restricted to non-operable patients. The extension of this treatment modality to less complex patient populations warrants a thorough comparison of safety and efficacy vis-a-vis SAVR. Perioperative mortality of SAVR for high-risk subpopulations such as octogenarians, patients with impaired LV function or previous sternotomy ranges from 5 to 19%. Peri-interventional mortality rates for TAVI amount to 6–23%. Reported stroke rates average 2–5% with both treatment modalities. While TAVI does not require cardiopulmonary bypass or general anesthesia, the spectrum of peri-interventional complications is extended to vascular access site complications as well as atrioventricular conductance disturban...