Although octogenarians undergoing transcatheter or surgical aortic valve replacement (TAVR or SAVR) experienced similar rates of in-hospital mortality and vascular complications, a recent analysis from the National Inpatient Sample concluded patients who received the less-invasive procedure had shorter hospital stays and fared better for a range of other outcomes.
The study, published Jan. 19 in the Journal of the American Heart Association, analyzed in-hospital outcomes for more than 19,000 elective TAVRs and nearly 10,000 elective SAVRs performed in patients in their 80s from 2012 to 2015. TAVR patients were a couple of years older on average and had a higher comorbidity burden at the time of their procedures.
After propensity scoring adjusted for age, sex, the year of the procedure, hospital characteristics, insurance coverage type and individual components of the Charlson Comorbidity Index (CCI), the researchers noted the following advantages for TAVR over SAVR:
- Lengths of stay 3.3 days shorter on average
- 66 percent lower odds of transfer to a skilled nursing facility
- 45 percent reductions for both acute kidney injury (AKI) and cardiogenic shock
- 56 percent lower odds of bleeding events
On the other hand, the adjusted odds of permanent pacemaker implantation, vascular complications, in-hospital mortality and transient ischemic attack or stroke were similar between groups.
“Even without adjusting for baseline characteristics, most in‐hospital outcomes were superior after TAVR than after SAVR,” wrote senior study author John P. Vavalle, MD, MHS, with the University of North Carolina, and colleagues. “These associations remained consistent across low and high CCI score groups, except for length of stay (significant reductions were still observed after TAVR in both groups), suggesting that these advantages of TAVR may apply to all octogenarians, irrespective of comorbidity burden.”
The authors pointed out about 10 percent of individuals in their 80s have calcific aortic stenosis, and the U.S. population of octogenarians is expected to double from 2020 to 2040—making it important to identify the best treatment practices for these individuals.
TAVR accounted for 48 percent of aortic valve replacements among octogenarians in 2012 but increased to 78 percent of AVRs in that population in 2015. Over that timeframe, the incidence of AKI, bleeding, vascular complications and blood transfusions were significantly reduced during TAVR hospitalizations, but the rate of permanent pacemaker implantation increased from 10 percent to 12 percent.
Average lengths of stay decreased both for TAVR (from 5.7 to 4.6 days) and SAVR (from 8.3 to 8.0 days) from the beginning to the end of the study period, as well. However, the proportion of discharges to a patient’s home increased only for TAVR.
The researchers noted they weren’t able to calculate conventional surgical risk scores from the NIS data, and instead opted to use CCI scores as a proxy for risk. Their study was also limited by the potential for coding errors inherent among database analyses.
Nevertheless, Vavalle et al. said the observed differences in length of stay and discharge location are particularly important to older patients, further pointing toward TAVR as the preferred approach for these patients. However, they wrote that additional TAVR versus SAVR studies in lower-risk octogenarians are needed to proclaim the transcatheter procedure as the best strategy for all patients in their 80s with aortic stenosis.
Although advanced age and frailty are commonly cited as reasons to prefer TAVR over SAVR, “the translation of this large consensus into clinical practice still remains heterogeneous,” noted the authors of a related editorial.
“With the expected results of low‐risk TAVR randomized trials in the next few months, the continued technological improvements, and the demographic projections, there is no doubt that TAVR will rapidly and universally become standard of care in octogenarians with severe aortic stenosis,” wrote Dominique Himbert, MD, and colleagues.