Morbidity and Mortality During Authorization Wait-Times for TAVR

For this Canada-based study, the increased number of patients who required a transcatheter aortic valve replacement (TAVR) may have come hand in hand with an equal increase in healthcare financing, so as to cover procedural costs. In spite of that, the wait-time between the formal request for authorization and the actual procedure was 3 months, and the rates of morbidity and mortality during this period were significant among this high-risk population.

The paradigm shift represented by TAVR offered therapeutic options for a high number of patients who, up to a few years ago, underwent aortic valvuloplasty only as a compassionate measure. Theoretically, this increase in the demand may overwhelm capacity, thus translating into prolonged wait-times to the procedure.

The aim of this work was to assess current delays of the procedure and to, eventually, associate them with clinical consequences during wait-times.

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The study analyzed a Canadian population of patients referred for TAVR between 2010 and 2016. The primary endpoint was the mean total wait-time from patient referral to actual procedure. The clinical endpoints were all-cause death and heart failure readmissions while on the wait-list.

The study included a total of 4461 patients referred for TAVR, of whom only 50% actually underwent the procedure. Additionally, 39% were ruled out for different reasons and 11% were still waiting for authorization at the conclusion of this study.

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For the half-cohort of patients who eventually underwent the procedure, the mean wait-time was 80 days, a statistic that remained stable for the 6 years analyzed by this study. For these patients, the probability of wait-list mortality was 2% and the probability of heart failure readmission was 12%. Obviously, the longer the wait-time, the higher the rates of mortality and readmission.

Conclusion

Wait-times between patient referral for TAVR and the actual procedure were relatively constant during the 6 years studied in this work, which suggests that the increased demand may have been met through healthcare financing.

This is true for Canada, where the study took place, but similar outcomes seem highly unlikely for Latin America. In these countries, wait-times are sometimes more linked to current political and economic realities than to patient-specific clinical context. Wait-times are directly associated with mortality and heart failure readmissions.

Original title: Temporal Trends and Clinical Consequences of Wait-Times for Trans-Catheter Aortic Valve Replacement: A Population Based Study.

Reference: Elbaz-Greener G et al. Circulation. 2018 Mar 6. Epub ahead of print.

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