Interventions for valvular disease and heart failure

The changing landscape of aortic valve replacement in the USA

EuroIntervention 2019;15:e968-e974. DOI: 10.4244/EIJ-D-19-00381

Tanush Gupta
Tanush Gupta1, MD; Dhaval Kolte2, MD, PhD; Sahil Khera3, MD; Kashish Goel4, MD; Pedro A. Villablanca5, MD, MSc; Ankur Kalra6, MD; J. Dawn Abbott7, MD; Sammy Elmariah2, MD, MPH; Gregg C. Fonarow8, MD; Charanjit S. Rihal9, MD; Mario J. Garcia1, MD; Giora Weisz1,10, MD; Deepak L. Bhatt11, MD, MPH
1. Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; 2. Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 3. Columbia University Medical Center, New York, NY, USA; 4. Vanderbilt University Medical Center, Nashville, TN, USA; 5. Henry Ford Health System, Detroit, MI, USA; 6. Cleveland Clinic Foundation, Cleveland, OH, USA; 7. Rhode Island Hospital, Brown University, Providence, RI, USA; 8. David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; 9. Mayo Clinic, Rochester, MN, USA; 10. Cardiovascular Research Foundation, New York, NY, USA; 11. Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA

Aims: The aim of this study was to analyse the real-world national data on parallel utilisation of transcatheter (TAVR) and surgical (SAVR) aortic valve replacement.

Methods and results: We queried an all-payer, administrative United States in-patient database to identify all AVR hospitalisations in patients aged ≥18 years from January 2012 to December 2016 and examined the temporal changes in the number of AVR procedures and in-hospital mortality. A total of 463,675 AVRs were performed – 363,275 (78.4%) SAVR and 100,400 (21.6%) TAVR. AVR linearly increased (from 78,985 in 2012 to 103,415 in 2016; +30.9%; ptrend<0.001) largely due to a marked increase in TAVR (from 7,655 to 33,545; +338%; ptrend<0.001), whereas the absolute number of SAVRs remained relatively stable (from 71,330 to 69,870; –1%; ptrend<0.001). The number of TAVRs increased in all pre-specified age groups (<75, 75-79, 80-85, and ≥85 years; ptrend<0.001 for all). In contrast, the number of SAVRs increased modestly in patients aged <75 years (ptrend<0.001) and declined in those aged 75-79 years, 80-84 years, or ≥85 years (ptrend<0.001 for all). Age- and sex-adjusted in-hospital mortality after isolated (aOR 1.00 [0.95-1.05]; ptrend=0.96) or combined SAVR (aOR 1.01 [0.97-1.05]; ptrend=0.66) remained unchanged during the study period, whereas in-hospital mortality after TAVR declined (aOR 0.75 [0.70-0.79]; ptrend<0.001). Similar trends in in-hospital mortality were seen in the age subgroups.

Conclusions: The number of AVRs markedly increased in the USA from 2012 to 2016, mainly due to the widespread adoption of TAVR, whereas the number of SAVRs remained relatively stable. In-hospital mortality after TAVR declined, whereas that after SAVR has remained unchanged.

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