Researchers examine ‘concerning’ out-of-hospital 30-day mortality rate for TAVR patients

Nearly one-third of transcatheter aortic valve replacement (TAVR) patients who die within 30 days do so after they have been discharged from the hospital, according to new findings published in JACC: Cardiovascular Interventions.

“The continued shift in treatment of severe aortic valve stenosis away from surgical aortic valve replacement toward TAVR in conjunction with incremental device improvements, increased procedural volumes, and operator experience has translated into improved mortality rates,” wrote lead author Saif Anwaruddin, MD, a cardiologist at Hospital of the University of Pennsylvania in Philadelphia, and colleagues. “During this period, TAVR has evolved by utilizing monitored anesthesia care in place of general anesthesia, avoidance of intensive care unit stays, and decreasing hospital length of stay. As this has taken place, it remains imperative to assess short-term outcomes following TAVR and to identify areas for improvement.”

Anwaruddin et al. explored data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, focusing on more than 98,000 patients who underwent transfemoral TAVR for severe aortic stenosis from January 2015 to March 2018. Patients were excluded from the analysis if they were discharged to another hospital or discharged when it was already 30 days after the procedure.

Overall, the all-cause mortality rate for TAVR patients was 2.2%, and 29% of those patients died out of the hospital. Out-of-hospital 30-day mortality was more likely among older patients, patients with a longer length of stay and patients with more medical comorbidities. A prior history of myocardial infarction, peripheral arterial disease, atrial fibrillation (AFib) or flutter, stroke or transient ischemic attack were also tied to a heightened risk of out-of-hospital 30-day mortality.

“That out-of-hospital mortality accounts for almost one-third of the 30-day mortality rate following transfemoral TAVR remains concerning,” the authors wrote. “Despite dramatic and immediate benefits to patients following TAVR, a successful procedure by itself is not assurance of avoiding early mortality after discharge.”

The research team also found that new onset AFib and pre-existing AFib were both specifically associated with a greater risk of out-of-hospital 30-day cardiovascular mortality.

“The thromboembolic events associated with AFib are not the only concern for mortality risk, as bleeding events related to anticoagulation, impaired coronary perfusion in the setting of uncontrolled heart rates, or potentiation of ventricular arrhythmias in higher-risk patients have been described as potential mechanisms of AFib or flutter–related mortality,” they wrote.

Anwaruddin et al. concluded with a call for more work in this area of research so that providers can better understand what leads to out-of-hospital mortality after 30 days for TAVR patients—and what can be done to prevent it.

The full analysis is available here.