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Inpatient complications from TAVR reduced over time

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Sameer Arora

CHICAGO — In an analysis of transcatheter and surgical aortic valve replacement procedures, TAVR was associated with reduced rates of inpatient complications over time and had lower rates of in-hospital stroke, cardiogenic shock, acute kidney injury and blood transfusion than surgery.

In 2015, the most recent year of the analysis, TAVR also had a lower rate of inpatient mortality compared with surgery.

Sameer Arora, MD, from the division of cardiology at the University of North Carolina School of Medicine, Chapel Hill, and colleagues analyzed TAVR and surgical AVR procedures from the National Inpatient Sample performed between 2012 and September 2015. The results were presented at the American Heart Association Scientific Sessions and published in Circulation: Cardiovascular Interventions.

“TAVR is a relatively new procedure. Although there have been a few single-center reports, a nationally representative study investigating trends in complications after TAVR over time is lacking. It was important to understand if TAVR has become safer over time,” Arora told Cardiology Today’s Intervention. “In this study, we trended inpatient complications over years 2012 to 2015 and found that the rates of inpatient complications have substantially decreased over time. The rates of mortality went down from 4% to 1%, and similarly we noticed improvement in rates of other complications.”

The cohort included 90,560 weighted hospitalizations, of which 40% were for TAVR and the rest for surgical AVR. Annual TAVR procedures (84% via transfemoral access) increased from 4,375 in 2012 to 12,125 in 2015.

Compared with those who underwent surgery, those who had TAVR were older (81 years vs. 70 years), more likely to be women (46% vs. 39%) and had a higher Charlson Comorbidity Index, which remained consistent over time (2.7 vs. 1.5; P < .001 for all).

According to the researchers, the following inpatient outcomes in TAVR patients declined between 2012 and 2015:

• mortality (from 4% to 1%);

• acute kidney injury (from 12% to 10%);

• vascular complications (from 8% to 5%);

• blood transfusions (from 31% to 10%); and

• cardiogenic shock (from 3% to 1%; P < .0001 for all).

During the study period, in the TAVR population, permanent pacemaker implantation rose over time (from 8% to 12%; P < .0001), and the rates of in-hospital stroke and cardiac arrest did not change significantly, according to the researchers.

Regarding inpatient complications after surgery, there was no change over time for permanent pacemaker implantation, stroke, vascular complications or cardiac arrest, but acute kidney injury increased (from 11% to 12%; P = .01) and mortality (from 1.7% to 1.3%; P = .0498), blood transfusions (from 37% to 24%; P < .0001) and cardiogenic shock (from 3% to 2%; P < .0001) declined.

After adjustments, compared with surgery, TAVR was associated with lower rates of inpatient stroke (incidence rate ratio [IRR] = 0.87; 95% CI, 0.76-0.99), cardiogenic shock (IRR = 0.54; 95% CI, 0.48-0.61), acute kidney injury (IRR = 0.72; 95% CI, 0.68-0.76) and blood transfusion (IRR = 0.43; 95% CI, 0.41-0.45), but higher rates of permanent pacemaker implantation (IRR = 1.59; 95% CI, 1.47-1.57), cardiac arrest (IRR = 1.17; 95% CI, 1.05-1.31), vascular complications (IRR = 1.1; 95% CI, 1-1.21) and mortality (IRR = 1.14; 95% CI, 1-1.31).

However, Arora and colleagues found that, in 2015, TAVR had a lower rate of inpatient mortality than surgery (IRR = 0.48; 95% CI, 0.37-0.63).

Transapical TAVR compared with surgery over time had a lower rate of permanent pacemaker implantation but a higher rate of stroke, acute kidney injury and inpatient mortality, according to the researchers.

“This has great implications for clinical practice, as a lot of myths about some of the higher rates of complications in the early TAVR years should now begin to shed,” Arora told Cardiology Today’s Intervention. “We also found a decline in some of the inpatient complications with [surgical] AVR as well, such as mortality went down from 1.7% to 1.3%. However, in case of TAVR, the decline was noted with almost all inpatient complications.” – by Erik Swain

References:

Arora S, et al. Poster Su4140. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.

Arora S, et al. Circ Cardiovasc Interv. 2018;doi:10.1161/CIRCINTERVENTIONS.118.007517.

Disclosures: Arora reports his spouse has a proprietary role in researchEZ LLC. Please see the study for a list of all other authors’ relevant financial disclosures.