Is TAVR at Hospitals Without Backup Cardiovascular Surgery Feasible?

Patients undergoing transcatheter aortic valve replacement (TAVR) at hospitals without cardiovascular surgery available are at significantly higher risk. That in itself is a call for attention; however, a propensity-matched analysis shows that the short- and long-term mortality rates are similar among patients treated at hospitals with and without cardiovascular surgery backup.

This debate emerged a few years ago in relation to coronary angioplasty, until the question was finally answered at the American Heart Association (AHA) 2016 Congress, reaching the conclusion that both alternatives were equally safe. However, there is a difference between treating coronary arteries nd treating a valve, where potential complications may reach an entirely different level.

This study included high-risk or inoperable patients with severe aortic stenosis who underwent the procedure at institutions with and without cardiovascular surgery available in case of complications. Current guidelines recommend that this procedure be conducted only at hospitals where surgery is available.

Read also: Aortic Stenosis and Dialysis: Is TAVR the Strategy of Choice?

Researchers evaluated 1822 consecutive patients from the Austrian TAVR registry; 290 (15.9%) underwent the procedure at a site with no available surgery, whereas the remaining 1532 patients (84.1%) were treated at sites with surgery permanently available.

Patients treated at sites with no surgical availability had a higher peri-operative risk, as defined by the EuroSCORE (20.9% vs. 14.2%; p < 0.001), compared with patients treated in higher-complexity hospitals.

Read also: AHA 2018 | Use of Balloon Counterpulsation According to IABP-SHOCK II Trial.

In an analysis of raw figures, peri-procedural survival in hospitals without surgery was 96.9% vs. 98.6% (p = 0.034), whereas 30-day survival was 93.1% vs. 96.0% (p = 0.039), and 1-year survival was 80.9% vs 86.1% (p = 0.017), respectively. The difference in risk among populations was an obvious confounding variable, among others, which warranted propensity score matching; after its use, all significant differences disappeared in all time points.

Conclusion

According to this study, patients undergoing transfemoral TAVR in hospitals without cardiovascular surgery have similar short- and long-term mortality rates compared with patients who undergo the same procedure in higher-complexity sites with a surgical team available in case of any complication. This is a consequence of the mass use of TAVR; however, many more studies are required for guidelines to be changed.

Original title: Impact of On-Site Cardiac Surgery on Clinical Outcomes After Transfemoral Transcatheter Aortic Valve Replacement.

Reference: Florian Egger et al. J Am Coll Cardiol Intv 2018;11:2160-7.

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