In-hospital Outcomes and the Impact of Transfer Status in Nonelective vs Elective Transcatheter Aortic Valve Replacement

Q: What are the key findings of this study?

Nonelective TAVR was associated with nearly double the odds of in-hospital mortality compared with elective TAVR.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) (n=8778). Intervention: Nonelective transcatheter aortic valve replacement (TAVR) vs. Elective transcatheter aortic valve replacement (TAVR). Primary outcome: In-hospital mortality (OR 1.99, 95% CI 1.42-2.81, p=<0.001).

Q: What does this research mean for the field?

Nonelective transcatheter aortic valve replacement is associated with nearly double the odds of in-hospital mortality compared with elective TAVR. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To compare in-hospital mortality and adverse procedural outcomes between patients undergoing nonelective versus elective transcatheter aortic valve replacement (TAVR), including stratification by transfer status.

Omar Al-Taweel; Ahmad Gill; Yousif Al-Baghdadi; Wilbur Ji; Nazanin Houshmand; Saba Al-Tarawneh; Chowdhury H. Ahsan

doi:10.1016/j.cjco.2023.03.005

March 11, 2023CJC OpenOpen Access

In-hospital Outcomes and the Impact of Transfer Status in Nonelective vs Elective Transcatheter Aortic Valve Replacement

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Key result

Nonelective TAVR is linked to ~99% higher odds of in-hospital mortality versus elective TAVR.

OR 1.99
95% CI 1.42-2.81
P<0.001
n=8,778

Why the study?

Nonelective transcatheter aortic valve replacement (TAVR) requires additional research to be fully understood, including its in-hospital outcomes and the impact of transfer status compared with elective TAVR.

Key Points

To compare in-hospital mortality and adverse procedural outcomes between patients undergoing nonelective versus elective transcatheter aortic valve replacement (TAVR), including stratification by transfer status.
Retrospective cohort analysis of the National Inpatient Sample database (2016–2019) identifying 160,290 TAVR admissions.
Performed 1:1 greedy nearest-neighbor propensity-score matching, resulting in 4389 patients in each cohort.
Utilized multivariable logistic regression adjusting for demographics, hospital characteristics, and comorbidities to assess in-hospital mortality and complications.
Nonelective TAVR patients had significantly higher odds of in-hospital mortality compared to elective admissions (adjusted odds ratio [aOR] 1.99, 95% CI: 1.42–2.81; P < 0.001).
In-hospital mortality remained higher for nonelective patients admitted as regular admissions (aOR 2.18, 95% CI: 1.38–3.46; P = 0.001) and acute-care transfers (aOR 2.12, 95% CI: 1.21–3.71; P = 0.01), but did not differ for non-acute-care transfers (P = 0.46).
Nonelective TAVR was associated with increased intraoperative cardiac arrest (OR 1.61, 95% CI: 1.07–2.43; P = 0.02), postoperative acute respiratory failure (OR 1.91, 95% CI: 1.40–2.63; P < 0.001), and postoperative cardiogenic shock (OR 2.16, 95% CI: 1.30–3.61; P = 0.003).

Study Design

Type

Cohort (n=8,778)

Multicenter

Yes

PICO

P

Population

8,778 propensity-matched hospitalized adults (mean age 80.0 years, 45.7% female) with severe aortic stenosis undergoing nonelective or elective TAVR in the United States from 2016 to 2019, followed until hospital discharge.

E

Exposure / Comparator

Nonelective transcatheter aortic valve replacement (TAVR) vs Elective transcatheter aortic valve replacement (TAVR)

O

Primary Outcome

In-hospital mortality — OR 1.99 (1.42-2.81), p=<0.001

Main Result

Odds Ratio: 1.99 (95% CI 1.42–2.81)

p-value: p=<0.001

Limitations

Inherent risk of miscoded diagnoses in the National Inpatient Sample administrative database
Lack of granular clinical and procedural data (aortic stenosis severity, LVEF, imaging results, access route, valve type, medications, readmissions, and post-discharge outcomes)
Inadequate capture of concomitant coronary artery disease, mitral regurgitation, and tricuspid regurgitation
Potential inconsistency across hospitals in defining elective versus nonelective procedures
Predominantly White cohort creating risk of type II error in racial subgroup analyses
Selection bias from propensity-score matching, which included only 19.2% (4,389 of 22,745) of nonelective TAVR patients

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May inform risk discussions for nonelective TAVR; observational data leave open whether optimized pathways reduce mortality.

Abstract

Background Nonelective transcatheter aortic valve replacement (TAVR) requires additional research to be fully understood. Methods Using the National Inpatient Sample database (2016-2019), we conducted a retrospective cohort study comparing nonelective vs elective TAVR. The primary outcome of interest was the in-hospital mortality rate among patients undergoing nonelective TAVR, compared to that among patients undergoing elective TAVR. We matched patients in a greedy nearest-neighbor 1:1 model and multivariable logistic regression, which was adjusted for demographics, hospital factors, and comorbidities, and was used to compare mortality in our matched cohort. Results Each cohort had 4389 patients in each cohort. When adjusted for age, race, sex, and comorbidities, nonelective TAVR patients had 1.99 times higher odds of suffering in-hospital mortality compared to elective admissions (adjusted odds ratio 1.99, 95% confidence interval: 1.42-2.81; P < 0.001). When separated by transfer status, nonelective patients admitted as regular hospital admissions or transferred from other acute-care centres also had higher odds of suffering in-hospital mortality compared to elective admissions. Conclusions Our findings illustrate that nonelective TAVR patients are a vulnerable population that require additional medical support in the acute-care setting. As the demand for TAVR increases, further discussions regarding access to healthcare in underserved regions, the national physician shortage, and the future of the TAVR industry are imperative.

Discussion

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Cite This Study

Al-Taweel et al. (2023) conducted a cohort in Aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) (n=8,778). Nonelective transcatheter aortic valve replacement (TAVR) vs. Elective transcatheter aortic valve replacement (TAVR) was evaluated on In-hospital mortality (OR 1.99, 95% CI 1.42-2.81, p=<0.001). Nonelective TAVR was associated with nearly double the odds of in-hospital mortality compared with elective TAVR.

synapsesocial.com/papers/6ae9625aa26b925ce198dda9 https://doi.org/10.1016/j.cjco.2023.03.005

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In-hospital Outcomes and the Impact of Transfer Status in Nonelective vs Elective Transcatheter Aortic Valve Replacement

Key Points

Study Design

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

In-hospital Outcomes and the Impact of Transfer Status in Nonelective vs Elective Transcatheter Aortic Valve Replacement

Key Points

Study Design

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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