Hospital Volume and Failure to Rescue Post-TAVR

BACKGROUND: There is an inverse volume-mortality relationship for transcatheter aortic valve replacement (TAVR), with higher adjusted mortality among hospitals with lower TAVR volumes. OBJECTIVES: The aim of this study was to identify potential mediators of the volume-mortality relationship including the risk of major complications occurring and/or failure to rescue (FTR) from these complications. METHODS: Using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, we identified patients who underwent TAVR from 2017 to 2023. The rate of FTR-defined as 30-day risk-adjusted mortality following a major complication post TAVR-was compared across hospitals stratified by quartiles (Q1-Q4) of annualized TAVR volume. RESULTS: A total of 487,159 patients (median age: 79 years, 57% male) who underwent TAVR across 808 sites were included. Lower-volume centers (Q1) had significantly higher rates of 30-day mortality (adjusted OR: 1.12; 95% CI: 1.00-1.25; P = 0.045) and major complications (adjusted OR: 1.19; 95% CI: 1.08-1.32; P = 0.0006) than higher-volume centers (Q4). The overall rate of FTR across all hospitals was 11.0%. There were no significant differences in FTR rates by hospital volume (adjusted OR: 0.97 per 100 cases; 95% CI: 0.93-1.01; P = 0.11) and no evidence of a threshold relationship. CONCLUSIONS: In this large contemporary study, we found that higher annualized TAVR volume was associated with lower complication rates but not with lower FTR rates. These findings suggest that the inverse relationship between hospital TAVR volume and post-TAVR mortality may be more strongly associated with complication rates than with FTR.