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Outcomes Following Urgent/Emergent Transcatheter Aortic Valve Replacement: Insights From the STS/ACC TVT Registry
Authors:Dhaval Kolte  Sahil Khera  Sreekanth Vemulapalli  Dadi Dai  Stephan Heo  Andrew M. Goldsweig  Herbert D. Aronow  Sammy Elmariah  Ignacio Inglessis  Igor F. Palacios  Vinod H. Thourani  Barry L. Sharaf  Paul C. Gordon  J. Dawn Abbott
Affiliation:1. Division of Cardiology, Brown University, Providence, Rhode Island;2. Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts;3. Division of Cardiology, Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina;4. Division of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska;5. Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC
Abstract:

Objectives

The authors sought to examine outcomes and identify independent predictors of mortality among patients undergoing urgent/emergent transcatheter aortic valve replacement (TAVR).

Background

Data on urgent/emergent TAVR as a rescue therapy for decompensated severe aortic stenosis (AS) are limited.

Methods

The Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry linked with Centers for Medicare & Medicaid Services claims was used to identify patients who underwent urgent/emergent versus elective TAVR between November 2011 and June 2016. Outcomes assessed were device success rate, in-hospital major adverse events, and 30-day and 1-year mortality. Independent predictors of mortality after urgent/emergent TAVR were examined.

Results

Of 40,042 patients who underwent TAVR, 3,952 (9.9%) were urgent/emergent (median STS PROM score 11.8 [interquartile range: 7.6 to 17.9]). Device success rate was statistically lower, but not clinically different after urgent/emergent versus elective TAVR (92.6% vs. 93.7%; p = 0.007). Rates of major and/or life-threatening bleeding, major vascular complications, myocardial infarction, stroke, new permanent pacemaker placement, conversion to SAVR, and paravalvular regurgitation were similar between the 2 groups. Compared with elective TAVR, patients undergoing urgent/emergent TAVR had higher rates of acute kidney injury and/or new dialysis (8.2% vs. 4.2%; p < 0.001), 30-day mortality (8.7% vs. 4.3%, adjusted hazard ratio: 1.28, 95% confidence interval: 1.10 to 1.48), and 1-year mortality (29.1% vs. 17.5%, adjusted hazard ratio: 1.20, 95% confidence interval: 1.10 to 1.31). In patients undergoing urgent/emergent TAVR, non-femoral access and cardiopulmonary bypass were associated with increased risk, whereas use of balloon-expandable valve was associated with decreased risk of 30-day and 1-year mortality.

Conclusions

Urgent/emergent TAVR is feasible with acceptable outcomes and may be a reasonable option in a selected group of patients with severe AS.
Keywords:aortic stenosis  cardiogenic shock  heart failure  mortality  transcatheter aortic valve implantation  transcatheter aortic valve replacement  ACC  American College of Cardiology  AKI  acute kidney injury  AS  aortic stenosis  AVR  aortic valve replacement  BAV  balloon aortic valvuloplasty  CI  confidence interval  CIAKI  contrast-induced acute kidney injury  CMS  Centers for Medicare & Medicaid Services  HR  hazard ratio  IQR  interquartile range  SAVR  surgical aortic valve replacement  STS  Society of Thoracic Surgeons  TAVR  transcatheter aortic valve replacement
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