Interventions for valvular disease and heart failure

Outcomes of stroke events during transcatheter aortic valve implantation

EuroIntervention 2022;18:e335-e344. DOI: 10.4244/EIJ-D-21-00951

Zaid Almarzooq
Zaid I. Almarzooq1,2, MBBCh; Dhruv S. Kazi1,3, MD, MS; Yun Wang1, PhD; Mabel Chung1,4, MD, MPH; Wei Tian1, MS; Jordan B. Strom1,3, MD, MSc; Suzanne J. Baron1,5, MD, MSc; Robert W. Yeh1,3, MD, MSc, MBA
1. Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA; 2. Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 3. Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 4. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; 5. Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA, USA

Background: Despite improvements in the safety of transcatheter aortic valve implantation (TAVI), ~4% of patients experience a procedure-related stroke. Understanding long-term health and healthcare implications of these events may motivate the development and adoption of preventative strategies. 

Aims: We aimed to assess the association of TAVI-related ischaemic stroke with subsequent clinical outcomes and healthcare utilisation.

Methods: We used Medicare fee-for-service claims to identify patients who underwent their first TAVI between January 2012 and December 2017. Previously used ICD-9-CM and ICD-10-CM codes were used to identify TAVI-related ischaemic stroke. Among those with and without TAVI-related ischaemic stroke, we compared the risk of a composite endpoint that included all-cause mortality, acute myocardial infarction, and subsequent stroke using inverse probability treatment weighted Cox regression. We also performed a difference-in-difference analysis to compare 1-year Medicare expenditures and days spent at home during the first year after TAVI.

Results: Among 129,628 primary TAVI patients, 5,549 (4.3%) had a procedure-related stroke. These patients were more likely to be female and have had prior stroke, peripheral vascular disease, ischaemic heart disease, or renal failure. After adjustment, TAVI-related ischaemic stroke was associated with a higher risk of the 1-year composite outcome (HR 1.67, 95% CI: 1.56–1.78), higher 1-year Medicare expenditures (difference $9,245 [standard error 790], p<0.001), and fewer days at home during the first year (difference 16 days [standard error 1], p<0.001).

Conclusions: Among Medicare beneficiaries undergoing TAVI, procedure-related ischaemic stroke was associated with worse outcomes, increased Medicare expenditures, and less time spent at home. Procedure-related ischaemic stroke during TAVI remains a critically important and potentially preventable source of patient mortality, morbidity and healthcare utilisation.

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