The incidence of aborted procedures during transcatheter aortic valve replacement (TAVR) is falling, according to work published in JACC: Cardiovascular Interventions, but centers with low institutional TAVR volume still struggle to keep up with bigger hospitals’ success.
Failed TAVR that requires physicians to either abort the procedure entirely or convert it to emergency open heart surgery is rare, Jennifer A. Rymer, MD, MBA, and colleagues wrote in the journal, but when those cases do surface they can have “catastrophic consequences.” Since aborted TAVRs are so few and far between, Rymer, of Duke University Medical Center, and colleagues said it’s been hard for researchers to characterize the problem.
Right now, the only data on aborted TAVR comes from the GARY registry—a German database that logged valve replacement surgeries between 2011 and 2013. Among 15,964 procedures performed in the two-year period, 5% were aborted or converted.
“However, little is known about whether the rate of aborted procedures has changed over time in the setting of lower-profile devices, improved pre-procedural imaging and greater technical ability, which may all contribute to reduced rates of abortion procedures,” Rymer et al. wrote. “Even less is known about the factors that may predict an aborted procedure and perhaps allow prevention of these often catastrophic events.”
The authors studied 106,169 patients who underwent elective TAVR between 2011 and 2017, using data from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry. They calculated both the incidence of procedures aborted because of device limitations (ADs) and those aborted for other reasons (AOs) over time.
Rymer and co-authors noted 581 ADs and 569 AOs in the study population, meaning the rate of aborted TAVRs during the six-year period settled around 1%. Women and patients with peripheral artery disease (PAD), chronic lung disease or kidney disease—as well as those treated at lower-volume TAVR centers—were more likely to experience both ADs and AOs.
Though it was rare, aborted TAVR was associated with poor outcomes—adjusted rates of 30-day death and stroke were five times higher in patients with aborted procedures compared to those with non-aborted procedures. Those patients were also four times more likely than their peers to experience bleeding or vascular complications at 30 days.
In a related editorial, Heath S.L. Adams, BMedSci, MBBS, and co-authors suggested referring tricky TAVR cases to more experienced centers could reduce the rate of aborted procedures. Improved transcatheter heart valve delivery systems and smaller sheaths are also on the horizon and will inevitably improve procedural outcomes.
“The rate of aborted procedures in contemporary TAVR practice is very low but will never be 0%,” the editorialists wrote. “Perhaps TAVR operators could liken the findings of this analysis to a historical phrase used in the British Army: ‘Prior Preparation Prevents Poor Performance.’ Careful patient assessment and heart team discussions are required in high-risk individuals with PAD and hazardous iliofemoral anatomy identified on pre-procedural computed tomography, to determine the appropriate access site, procedural strategy and bailout maneuvers where required.”