Modeling the impact of delaying transcatheter aortic valve replacement for the treatment of aortic stenosis in the era of COVID-19

Figures

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  Results from decision analysis favor prompt TAVR over delayed TAVR.

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  Figure 1. Decision analysis tree for the timing of transcatheter aortic valve replacement (TAVR) during the coronavirus disease 2019 (COVID-19) pandemic. The decision analysis tree demonstrates possible outcomes associated with either delaying TAVR or undergoing prompt TAVR. The availability of hospital resources during surges in COVID-19 infections may play a role in the decision to delay TAVR. The blue square indicates the decision node, whether to choose prompt or delayed TAVR; green circles, chance nodes; red triangles, terminal nodes. Numerical values for the chance nodes and terminal nodes are detailed in Tables 2 and 3.

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  Figure 2. Two-way sensitivity analysis for the probabilities of infection and mortality from coronavirus disease 2019 (COVID-19) in intermediate-risk patients. The graph displays the favored strategy (prompt or delayed transcatheter aortic valve replacement [TAVR]) across a range of all possible probabilities of contracting perioperative COVID-19 infection and COVID-19–related mortality while holding all other model variables constant at baseline values. For any given probability of mortality from COVID-19, one can estimate the probability of contracting COVID-19 in which the favored strategy changes from prompt TAVR to delayed TAVR. The vast majority of patients will benefit from prompt TAVR because they will fall into the left lower quadrant of the figure with a probability of either contracting COVID-19 or dying from it of <40%.

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  Figure 3. Two-way sensitivity analysis for the probability of infection and mortality from coronavirus disease 2019 (COVID-19) in low-risk patients. The graph displays the favored strategy (prompt or delayed transcatheter aortic valve replacement [TAVR]) across a range of possible probabilities of contracting perioperative COVID-19 infection and COVID-19–related mortality while holding all other model variables constant at baseline values. For any given probability of mortality from COVID-19, one can estimate the probability of contracting COVID-19 in which the favored strategy changes from prompt TAVR to delayed TAVR. The vast majority of patients will benefit from prompt TAVR because they will fall into the left lower quadrant of the figure with a probability of either contracting COVID-19 or dying from it of <40%.

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  Figure 4. Decision analysis for timing of transcatheter aortic valve replacement (TAVR) in the coronavirus disease 2019 (COVID-19) era. The decision analysis tree demonstrates possible outcomes for patients with severe aortic stenosis. The model predicts the benefit of prompt TAVR versus delayed TAVR based on the probabilities of acquisition or mortality from COVID-19 and favors prompt TAVR for the majority of probabilities likely to be encountered (red region).

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  Figure E1. Two-way sensitivity analysis for probability of undergoing urgent or emergent transcatheter aortic valve replacement (TAVR) or dying before repair during a 6-month delay due to the coronavirus disease 2019 (COVID-19) pandemic in intermediate-risk patients. The graph displays the favored strategy (prompt or delayed TAVR) across a range of possible probabilities of dying before surgery or requiring urgent/emergent repair while holding all other model variables constant at baseline values. Prompt TAVR is preferred in all clinically relevant circumstances, as the probability of undergoing urgent/emergent TAVR within 3 to 6 months is >5% based on the best available evidence, easily falling in the prompt TAVR area of >5%.

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  Figure E2. Two-way sensitivity analysis for the probability of undergoing urgent or emergent transcatheter aortic valve replacement (TAVR) or dying before repair during the 6-month delay due to the coronavirus disease 2019 (COVID-19) pandemic in low-risk patients. The graph displays the favored strategy (prompt or delayed TAVR) across a range of possible probabilities for dying before surgery or requiring urgent/emergent repair while holding all other model variables constant at baseline values. Prompt TAVR is preferred in all clinically relevant circumstances, as the probability of undergoing urgent/emergent TAVR within 3 to 6 months is >5% based on the best available evidence, easily falling in the prompt TAVR area of >5%.