Elective TAVR versus Urgent TAVR
Bianco et al. [1] report a single centre retrospective analysis of
1193 patients that underwent transcatheter aortic valve replacement
(TAVR) over an 8-year period from 2011-2018; of which 247 (20.7%) were
urgent and 946 were elective procedures. The authors compared the urgent
and elective procedure and studied in-hospital, short and mid-term
survival and hospital readmissions. They reported that the 30 day
mortality (6.5% vs 2.3%), acute kidney injury (2.8% vs 0.6%) and
length of stay (12 vs 3 days) were all significantly higher in the
urgent group vs those having elective TAVR procedures, respectively.
Freedom from readmission for heart failure at 1-year was lower for the
urgent group (73.6% vs 83.4%), and the 1-year (79.0% vs 87.1%) and
5-year (39.6% vs 43.5%) survival was lower in this group vs the
elective group, although this difference was eliminated after risk
adjustment. The authors conclude although urgent TAVR is associated with
increased periprocedural risk due to more co-morbid disease, outcomes
and long-term survival support the consideration of urgent TAVR as a
viable alternative for this patient population.
This is an important topic for cardiologists and cardiac surgeons
because of the relative frequency of patients with severe aortic
stenosis (AS) admitted to hospital with related symptoms and heart
failure. Although most patients with heart failure can be medically
managed with subsequent discharge and elective intervention, this may
put them at a higher risk for recurrent heart failure and readmission.
Moreover, acute heart failure and cardiogenic shock in severe AS are
associated with poor prognoses, as well as an extremely high operative
risk for surgical aortic valve replacement (SAVR) [2-4].
Institutional practices, local and logistic factors can affect patient
selection and management approaches to severe aortic stenosis. Although
TAVR is generally performed on an appropriate basis, there is still a
need to determine how to best manage the list for TAVR as well as to
develop benchmarks for the maximum acceptable waiting time for patients
with severe AS pending intervention. In addition, the potential benefit
of TAVR needs to be weighed against the periprocedural risks and the
likelihood of futility.