E. Faridmoayer1, S. Sharath1, A. Salami2, J. K. An1, L. Haefner1, S. Noh1, P. Kougias1 1Downstate Health Sciences University, Department Of Surgery, Brooklyn, NY, USA 2University Of Minnesota, Division Of Cardiothoracic Surgery, Department Of Surgery, Minneapolis, MN, USA
Introduction:
Since 2011, transcatheter aortic valve replacement (TAVR) has become an increasingly common alternative to open surgical valve replacement (SAVR) for patients with critical aortic valve stenosis. The objective of this study was to compare trends and predictors of in-hospital mortality between the two interventions.
Methods:
We conducted a retrospective cohort study utilizing the National Inpatient Sample database. ICD 9 and ICD 10 codes were used to identify patients who underwent TAVR and SAVR as primary or secondary procedures with an indication for aortic stenosis. Patients with congenital aortic valve disorders, rheumatic valve disease, and hypertrophic cardiomyopathy were excluded. Demographics, highly prevalent comorbidities, region, and payor types were included as potential predictors. The primary outcome was postoperative in-hospital mortality. Logistic regression models were used to identify mortality predictors. An interaction term was used to describe changes in mortality risk over time.
Results:
Between 2011 and 2019, 118,748 patients underwent aortic valve replacement. 75,269 (63.4%) underwent SAVR and 43,479 (36.6%) underwent TAVR. The overall unadjusted rate of mortality for SAVR vs. TAVR was 2.3% vs. 1.6%, respectively (p<0.001). In a fully adjusted model, TAVR had a clear survival benefit compared to SAVR (odds ratio [OR], 0.55; 95% Confidence Interval [CI], 0.49-0.62; p<0.001). Predictors of increased mortality risk included age (OR, 1.03; 95% CI, 1.025-1.03; p<0.001), female gender (OR, 1.38; 95% CI, 1.27-1,49; p<0.001), stage IV chronic kidney disease (CKD) (OR, 2.04; 95% CI, 1.62-2.56; p<0.001), and stage V CKD (OR, 3.75; 95% CI, 3.15-4.45; p<0.001). Regional variations in mortality risk were also observed in the Midwest (OR, 1.20; 95% CI, 1.06-1.36; P=0.005) and South (OR, 1.52; 95% CI, 1.36-1.7; p<0.001) compared to Northeast. The interaction between operation type and year was highly significant, indicating that mortality risks changed over time by operation type (Figure). For SAVR, mortality risks remained relatively stable compared to the pronounced decrease in mortality risk after TAVR during the study period.
Conclusion:
TAVR was associated with lower in-hospital mortality risk compared to SAVR among patients undergoing aortic valve replacement. In addition, the probability of mortality risk after TAVR substantially decreased over the 8-year study period. This decrease in risk could be explained by improvements in TAVR-related technology and technical skill, evolving postoperative management, and broadening the TAVR inclusion criteria to include lower-risk patients. This can be cautiously used as supporting evidence in offering TAVR to appropriately selected patients.
