There are increasingly more patients who have undergone transcatheter aortic valve replacement (TAVR) and require a non-cardiac intervention, or patients with other diseases who need surgery and are diagnosed with aortic stenosis.
In addition, on many occasions, surgery must be performed as soon as possible (as in cases of cancer) or is an emergency procedure. In these scenarios, TAVR could be the strategy of choice due to its rapid patient recovery, although this is yet to be demonstrated in large studies.
Researchers conducted an analysis of 2238 patients from the Bern Registry. Of that total, 300 underwent non-cardiac surgery after TAVR (13.4%), 160 underwent elective TAVR, and 140 underwent emergency or urgent TAVR.
The primary endpoint (PEP) at 30 days after non-cardiac surgery was a composite of all-cause mortality, stroke, infarction, and major bleeding.
The mean age was 81 years, 52% of patients were men, 85% had hypertension, 32% had diabetes, 61% had coronary artery disease, 13% had peripheral vascular disease, and renal function was preserved.
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The most frequent surgeries were neurological and orthopedic, followed by superficial and intraperitoneal surgeries.
In 21% of patients, surgery was performed within 30 days after TAVR; in 25%, between day 31 and 180; in 23%, between day 181 and 365, and in 31%, after one year.
The surgical risk was low in 7% of cases, intermediate in 63.3% and high in 29.7%.
The PEP at 30 days occurred in 58 patients (Kaplan-Meier estimate: 19.7%; 95% confidence interval [CI]: 15.6%-24.7%), all-cause mortality in 28 (Kaplan-Meier estimate: 9.6%; 95% CI: 6.7%-13.5%), stroke in 3, (Kaplan-Meier estimate: 1.1%; 95% CI: 0.3%-3.2%), infarction in 1 (Kaplan-Meier estimate: 0.4%; 95% CI: 0.1%-2.6%), and major bleeding in 33 patients (Kaplan-Meier estimate:11.3%; 95% CI: 8.2%-15.6%).
A multivariate analysis showed that the presence of moderate or severe paravalvular regurgitation and the existence of moderate to severe mismatch were independently associated with a higher risk of events at 30 days in non-cardiac surgery after TAVR.
Conclusion
These findings suggest that non-cardiac surgery can be performed early after TAVR. Suboptimal device outcome, such as prosthetic mismatch and paravalvular regurgitation, is associated with an increased risk of adverse outcomes after non-cardiac surgery.
Dr. Carlos Fava.
Member of the editorial board of SOLACI.org.
Original Title: Risk and Timing of Noncardiac Surgery After Transcatheter Aortic Valve Implantation.
Reference: Taishi Okuno, MD, et al. JAMA Network Open. 2022;5(7):e2220689. doi:10.1001/jamanetworkopen.2022.20689.
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