J. Hadaya1, E. Aguayo1, O. Kwon1, A. Vadlakonda1, B. Cho1, R.J. Shemin1, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA
Introduction:
Transcatheter aortic valve replacement (TAVR) carries risk of major intraoperative complications such as coronary obstruction or aortic/cardiac perforation, which require emergency cardiac surgery, or surgical bailout. We evaluate contemporary outcomes of patients requiring surgical bailout after TAVR, and tested the association of cardiac surgical volume and TAVR volume with surgical bailout and outcomes.
Methods:
Adults undergoing TAVR from 2016-2021 were identified in the Nationwide Readmission Database. Patients were grouped based on surgical bailout (SB), which was defined as cardiac surgery following TAVR. The primary outcome was in-hospital mortality, while secondary outcomes included major adverse cardiovascular events (MACE), mechanical circulatory support (MCS), length of stay (LOS), hospitalization costs, and 30-day nonelective readmission. Multivariable logistic and linear regression was used to evaluate the association of SB and TAVR or cardiac surgery volume on primary and secondary outcomes.
Results:
Among 408,779 patients meeting study criteria, 0.4% experienced surgical bailout. The SB group was younger (72.5 vs 78.8 years, p<0.001), more commonly male (60.1% vs 56.1%, p=0.03), and had a greater burden of chronic diseases (Elixhauser Index 6.5 vs 5.6, p<0.001) relative to others. The most common operations performed were isolated CABG (33.5%), SAVR ± CABG (30.3%), aortic replacement ± SAVR (12.4%), and mitral valve surgery (5.2%). In-hospital mortality was significantly greater for those undergoing SB (24.8% vs 1.2%), as were MCS use (71.1% vs 1.9%), MACE (32.7% vs 5.0%), LOS (10 vs 2), hospitalization costs ($92,300 vs $47,300), and 30-day nonelective readmission (14.9% vs 10.6%, all p<0.001). After adjustment for patient, hospital, and operative factors, SB was associated with increased odds of mortality (21.5, 95% CI 17.1-26.9); similarly, SB was associated with greater odds of MACE and MCS use, and greater risk-adjusted LOS and costs. There was an inverse relationship between TAVR volume and incidence of SB, but minimal influence of cardiac surgery volume on SB (Figure). When studied by quartile, operations at high volume TAVR programs were associated with reduced odds of SB, while there was no association with cardiac surgical volume. Neither TAVR volume nor cardiac surgical volume influenced mortality following SB.
Conclusion:
Although rare, SB is associated with high morbidity and mortality following TAVR, and is more common at low volume programs. These findings emphasize the continued relevance of multidisciplinary heart teams and minimum volume requirements for TAVR.