Repeat TAVR Outcomes

Aug 10, 2021
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Authors:
Percy ED, Harloff MT, Hirji S, et al.
Citation:
Nationally Representative Repeat Transcatheter Aortic Valve Replacement Outcomes: Report From the Centers for Medicare and Medicaid Services. JACC Cardiovasc Interv 2021;14:1717-26.
Summary By:
Sherrie R. Webb, PA-C

Quick Takes

  • In a national study of all Medicare patients from 2012 to 2017, repeat TAVR had an acceptable 30-day mortality rate of 6.0%.
  • However, 1-year mortality of 21% did not significantly differ between repeat TAVR and surgical TAVR explantation in a cohort of matched patients.
  • Mortality with repeat TAVR was significantly improved in 2015-2017 compared with 2012-2014.

Study Questions:

What is known about outcomes of repeat transcatheter aortic valve replacement (TAVR)?

Methods:

Using the US Medicare Provider Analysis Review and Master Beneficiary Summary Files, investigators identified 617 isolated TAVR patients who subsequently underwent repeat TAVR during the years 2012 through 2017. Primary study endpoints were overall incidence of repeat TAVR, time to event, 30-day mortality (defined to include all-cause mortality within 30 days or during the index procedure hospitalization if the postoperative length of stay exceeded 30 days), and 1-year mortality. Patients were excluded from the study if not discharged alive or if discharged to hospice after initial TAVR. Also excluded were patients undergoing open surgical procedures or repeat TAVR during the same admission for an acute device or procedural failure.

Results:

Of 133,250 patients who underwent primary TAVR during 2012 through 2017, 617 (0.46%) underwent repeat TAVR. Median time from first TAVR to subsequent TAVR was 154 days, although 10.9% underwent repeat TAVR within 30 days of initial TAVR. Average age of patients undergoing repeat TAVR was 80.8 ± 8.9 years. The rate of 30-day mortality was 6.0% and was significantly lower in patients who underwent initial TAVR during 2015-2017 compared with 2012-2014 (4.6% vs. 8.7%; p = 0.049). The rate of 1-year mortality was 22.0%; it was also significantly lower in patients who underwent initial TAVR in 2015-2017 compared with 2012-2014 (19.0% vs. 28.2%; p = 0.013). The investigators also conducted an analysis of 257 repeat TAVR patients matched to 130 surgical TAVR explantation patients, based on 21 demographic and comorbidity characteristics selected due to their importance in progression of aortic valve disease. Although repeat TAVR was associated with lower 30-day mortality than TAVR explant (6.2% vs. 12.3%; odds ratio 1.98; 95% confidence interval, 1.02-3.83; p = 0.050), mortality at 1 year did not significantly differ between the groups (21.0% vs. 20.8%; p = 1.00). The survival trend remained significant regardless of whether initial TAVR was performed in 2012-2014 or 2015-2017. Overall longitudinal survival was increased with explantation in comparison with repeat TAVR (hazard ratio 1.40; 95% confidence interval, 1.00-1.80; p = 0.049).

Conclusions:

Approximately 1 in 215 patients underwent repeat TAVR, which was associated with an acceptable 6.0% short-term mortality in a high-risk population. Although outcomes at 30 days were superior with repeat TAVR compared with surgical TAVR explantation, outcomes at 1 year did not significantly differ between the groups. Overall longitudinal survival was decreased with repeat TAVR in comparison with explantation. As use of TAVR in younger individuals increases, the risks and benefits of repeat interventions should be considered by both providers and patients at the time of initial valve replacement. This study provides an initial contribution to the data needed in the shared decision-making process.

Perspective:

Outcomes of this study provide an interesting comparison with those of the international Redo-TAVR registry (doi: 10.1016/j.jacc.2020.02.051). That study reported 30-day mortality of 2.8% and 1-year mortality of 13.5% (5.4% and 16.4%, respectively, if within 1 year of initial TAVR). The authors suggest that differences in mortality between these studies were likely due to 1) inclusion of all Medicare TAVR patients in the US study as opposed to only those from specialized centers, 2) a greater proportion of reintervention cases within 1 year of initial TAVR, 3) a higher burden of comorbidities, and 4) a larger proportion of patients undergoing initial TAVR in the earlier 2012-2014 era.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease

Keywords: Transcatheter Aortic Valve Replacement, Centers for Medicare and Medicaid Services, U.S., Risk Assessment, Risk Factors, Medicare, Decision Making, Aged


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