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Damluji AA, Nanna MG, Rymer J, Kochar A, Lowenstern A, Baron SJ, Narins CR, Alkhouli M. Chronological vs Biological Age in Interventional Cardiology: A Comprehensive Approach to Care for Older Adults: JACC Family Series. JACC Cardiovasc Interv 2024; 17:961-978. [PMID: 38597844 PMCID: PMC11097960 DOI: 10.1016/j.jcin.2024.01.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 04/11/2024]
Abstract
Aging is the gradual decline in physical and physiological functioning leading to increased susceptibility to stressors and chronic illnesses, including cardiovascular disease. With an aging global population, in which 1 in 6 individuals will be older than 60 years by 2030, interventional cardiologists are increasingly involved in providing complex care for older individuals. Although procedural aspects remain their main clinical focus, interventionalists frequently encounter age-associated risks that influence eligibility for invasive care, decision making during the intervention, procedural adverse events, and long-term management decisions. The unprecedented growth in transcatheter interventions, especially for structural heart diseases at extremes of age, have pushed age-related risks and implications for cardiovascular care to the forefront. In this JACC state-of-the-art review, the authors provide a comprehensive overview of the aging process as it relates to cardiovascular interventions, with special emphasis on the difference between chronological and biological aging. The authors also address key considerations to improve health outcomes for older patients during and after their invasive cardiovascular care. The role of "gerotherapeutics" in interventional cardiology, technological innovation in measuring biological aging, and the integration of patient-centered outcomes in the older adult population are also discussed.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Fairfax, Virginia, USA; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael G Nanna
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Rymer
- Duke University School of Medicine, Durham, North Carolina USA
| | - Ajar Kochar
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zhou C, Xia Z, Song Y, Lian Z. Transcatheter versus surgical aortic valve replacement in patients with aortic regurgitation: A propensity-matched analysis. Heliyon 2023; 9:e16734. [PMID: 37303509 PMCID: PMC10248226 DOI: 10.1016/j.heliyon.2023.e16734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023] Open
Abstract
This study aimed to analyze in-hospital and early-to-interim outcomes of pure aortic regurgitation (AR) using transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR). Background Few studies have discussed and compared the safety and short-term prognosis of TAVR and SAVR in pure AR patients. As such, we looked to the National Readmissions Database (NRD) for records between 2016 and 2019 in order to identify patients diagnosed with pure AR who underwent SAVR or TAVR. We used the propensity score matching to minimize disparities between two groups. We included 23,276 pure AR patients: 1983 (8.5%) who underwent TAVR and 21,293 (91.5%) who underwent SAVR. We found 1820 matched pairs using propensity score matching. In the matching cohort, TAVR was associated with a low risk of in-hospital mortality. Although TAVR had lower incidences of 30-day all-cause readmission (hazard ratio (HR):0.73, 95% confidence interval (CI): 0.61-0.87; P < 0.01) and 6-month all-cause readmission (HR: 0.81, 95% CI: 0.67-0.97; P = 0.03), while TAVR had high incidences of 30-day permanent pacemaker implantation incidence (HR: 3.54, 95% CI: 1.62-7.74; P < 0.01) and 6-month permanent pacemaker implantation incidence (HR: 4.12, 95% CI: 1.17-14.4; P = 0.03).In conclusion, TAVR and SAVR had similar risks of hospital death and lower rates of 30-day and 6-month all-cause and cardiovascular readmission. But TAVR had a higher risk of permanent pacemaker implantation than SAVR in AR patients, suggesting that TAVR can be performed safely in pure AR patients.
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Affiliation(s)
| | | | | | - Zhexun Lian
- Corresponding author. No 16 Jiangsu Road, Shinan District, Qingdao, Shandong Province, China.
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Weinberg L, Walpole D, Lee DK, D'Silva M, Chan JW, Miles LF, Carp B, Wells A, Ngun TS, Seevanayagam S, Matalanis G, Ansari Z, Bellomo R, Yii M. Modern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study. Front Cardiovasc Med 2022; 9:865008. [PMID: 35911518 PMCID: PMC9330044 DOI: 10.3389/fcvm.2022.865008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background There have been multiple recent advancements in the selection, optimisation and management of patients undergoing cardiac surgery. However, there is limited data regarding the outcomes in nonagenarians, despite this cohort being increasingly referred for these interventions. The objective of this study was to describe the patient characteristics, management and outcomes of a cohort of nonagenarians undergoing cardiac surgery receiving contemporary peri-operative care. Methods After receiving ethics approval, we conducted a retrospective observational study of nonagenarians who had undergone cardiac surgery requiring a classic median sternotomy. All operative indications were included. We excluded patients who underwent transcatheter aortic valve implantation (TAVI), and surgery on the thoracic aorta via an endovascular approach (TEVAR). Patients undergoing TEVAR often have the procedure done under sedation and regional blocks with local anesthetic solution. There is no open incision and these patients do not require cardiopulmonary bypass. We also excluded patients undergoing minimally invasive mitral valve surgery via a videoscope assisted approach. These patients do not have a median sternotomy, have the procedure done via erector spinae block, and often are extubated on table. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012–December 2019). The primary objective was to assess 6-month mortality in nonagenarian patients undergoing cardiac surgery and to provide a detailed overview of postoperative complications. We hypothesized that cardiac surgery in nonagenarian patients would be associated with a 6-month postoperative mortality <10%. As a secondary outcome, we hypothesized that significant postoperative complications (i.e., Clavien Dindo Grade IIIb or greater) would occur in > 30% of patients. Results A total of 12,358 adult cardiac surgery patients underwent surgery during the study period, of whom 18 nonagenarians (0.15%) fulfilled inclusion criteria. The median (IQR) [min-max] age was 91.0 years (90.0:91.8) [90–94] and the median body mass index was 25.0 (kg/m2) (22.3:27.0). Comorbidities, polypharmacy, and frailty were common. The median predicted mortality as per EuroSCORE-II was 6.1% (4.1:14.5). There were no cases of intra-operative, in-hospital, or 6-month mortality. One (5.6%) patient experienced two Grade IIIa complications. Three (16.7%) patients experienced Grade IIIb complications. Three (16.7%) patients had an unplanned hospital readmission within 30 days of discharge. The median value for postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others were discharged to an inpatient rehabilitation facility. Conclusion In this selected, contemporary cohort of nonagenarian patients undergoing cardiac surgery, postoperative 6-month mortality was zero. These findings support carefully selected nonagenarian patients being offered cardiac surgery (Trials Registry: https://www.anzctr.org.au/ACTRN12622000058774.aspx).
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Affiliation(s)
- Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Laurence Weinberg
| | - Dominic Walpole
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Michael D'Silva
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Jian Wen Chan
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Lachlan Fraser Miles
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Bradly Carp
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Adam Wells
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, VIC, Australia
| | - Tuck Seng Ngun
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Health, Melbourne, VIC, Australia
| | - Ziauddin Ansari
- Department of Intensive Care, Epworth Eastern Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Michael Yii
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, VIC, Australia
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Elsisy MF, Schaff HV, Crestanello JA, Alkhouli MA, Stulak JM, Stephens EH. Outcomes of cardiac surgery in nonagenarians. J Card Surg 2022; 37:1664-1670. [DOI: 10.1111/jocs.16396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/14/2022] [Accepted: 02/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Mohamed F. Elsisy
- Department of Cardiovascular Surgery Mayo Clinic Rochester Minnesota USA
| | - Hartzell V. Schaff
- Department of Cardiovascular Surgery Mayo Clinic Rochester Minnesota USA
| | | | | | - John M. Stulak
- Department of Cardiovascular Surgery Mayo Clinic Rochester Minnesota USA
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Latif A, Ahsan MJ, Lateef N, Kapoor V, Mirza MM, Anwer F, Del Core M, Kanmantha Reddy A. Outcomes of surgical versus transcatheter aortic valve replacement in nonagenarians- a systematic review and meta-analysis. J Community Hosp Intern Med Perspect 2021; 11:128-134. [PMID: 33552435 PMCID: PMC7850375 DOI: 10.1080/20009666.2020.1843235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction: Since the approval of transcatheter aortic valve replacement (TAVR), nonagenarian group patients are being increasingly considered for TAVR. Therefore, we compared the clinical outcomes of surgical aortic valve replacement (SAVR) vs TAVR in nonagenarians with severe aortic stenosis. Methods: A literature search was performed using MEDLINE, Embase, Web of Science, Cochrane, and Clinicaltrials.gov for studies reporting the comparative outcomes of TAVR versus SAVR in nonagenarians. The primary endpoint was short-term mortality. Secondary endpoints were post-operative incidences of stroke or transient ischemic attack (TIA), vascular complications, acute kidney injury (AKI), transfusion requirement, and length of hospital stay. Results: Four retrospective studies qualified for inclusion with a total of 8,389 patients (TAVR = 3,112, SAVR = 5,277). Short-term mortality was similar between the two groups [RR = 0.91 (95% CI: 0.76–1.10), p = 0.318]. The average length of hospital stay was shorter by 3 days in the TAVR group (p = 0.037). TAVR was associated with a significantly lower risk of AKI [RR = 0.72 (95% CI: 0.62–0.83), p < 0.001] and a lower risk of transfusion [RR = 0.71 (95% CI: 0.62–0.81), p < 0.001]. There was no difference in risk of stroke/TIA[RR = 1.01 (95% CI: 0.70–1.45), p = 0.957]. The risk of vascular complications was significantly higher in the TAVR group [RR = 3.39 (95% CI: 2.65–4.333), p < 0.001]. Conclusion: In this high-risk population, TAVR compared to SAVR has similar short-term mortality benefit but has lower risks of perioperative complications and a higher number of patients being discharged to home.
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Affiliation(s)
- Azka Latif
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Muhammad Junaid Ahsan
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Noman Lateef
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Vikas Kapoor
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Mohsin Mansoor Mirza
- Department of Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | | | - Michael Del Core
- Department of Cardiology, CHI Health Heart and Vascular Institute, Omaha, Nebraska
| | - Arun Kanmantha Reddy
- Department of Cardiology, CHI Health Heart and Vascular Institute, Omaha, Nebraska
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Kawsara A, Sulaiman S, Linderbaum J, Coffey SR, Alqahtani F, Nkomo VT, Crestanello JA, Alkhouli M. Temporal Trends in Resource Use, Cost, and Outcomes of Transcatheter Aortic Valve Replacement in the United States. Mayo Clin Proc 2020; 95:2665-2673. [PMID: 33168160 DOI: 10.1016/j.mayocp.2020.05.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/27/2020] [Accepted: 05/28/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the contemporary trends in outcomes and resource use associated with transcatheter aortic valve replacement (TAVR) in the United States. METHODS We identified patients who underwent TAVR between January 1, 2012, and December 31, 2017, in the National Readmission Database. We assessed temporal trends in clinical outcomes, length-of-stay, non-home discharges, and cost of the index TAVR hospitalization. We also evaluated the changes in the burden of hospitalizations before and after TAVR. RESULTS A total of 89,202 patients were included. In-hospital mortality decreased from 5.3% (188) in 2012 to 1.6% (484) in 2017 (adjusted odds ratio: 0.37, 95% CI: 0.30 to 0.46). Risk-adjusted incidences of new dialysis, vascular complications, blood transfusion, and mechanical ventilation decreased, but strokes and pacemaker implantations remained unchanged. Length of stay decreased from median of 7 (interquartile range [IQR]: 4 to 11) to 2 (IQR: 2 to 5) days (P<.001). Risk-adjusted non-home discharges decreased from 32.2% (1134) to 15.5% (386) (P<.001). Median cost of the TAVR hospitalization decreased from $56,022 (IQR: $43,690 to $75,174) to $46,101 (IQR: $36,083 to $59,752) (P<.001). Pre-TAVR admissions at 30, 90, and 180 days decreased from 21.6% (713), 39.5% (1160), and 50.5% (1009) in 2012 to 15.5% (4451), 30.2% (7186), and 36.8% (5928) in 2017, respectively (P<.001). Similarly, re-hospitalizations at 30, 90, and 180 days post-TAVR decreased from 17.5% (531), 27.9% (657), and 34.2% (521) to 12.4% (3486), 21.1% (4783), and 29.1% (4306), respectively (P<.001). The expenditure on index, pre-, and post-TAVR hospitalizations increased from $0.53 to $2.8 billion between 2012 and 2017. CONCLUSION This study reflects the changes in the characteristics and outcomes of TAVR in the United States between 2012 and 2017. It also shows the temporal decrease in resource use, cost, and burden of hospitalizations among patients undergoing TAVR in the United States, but an increase in the overall expenditure on TAVR-related hospitalizations.
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Affiliation(s)
- Akram Kawsara
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, WV
| | - Samian Sulaiman
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, WV
| | - Jane Linderbaum
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN
| | - Sarah R Coffey
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN
| | - Fahad Alqahtani
- Division of Cardiology, Department of Medicine, University of Kentucky, Lexington, KY
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic School of Medicine, Rochester, MN
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN.
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Deharo P, Bisson A, Herbert J, Lacour T, Saint Etienne C, Theron A, Porto A, Collart F, Bourguignon T, Cuisset T, Fauchier L. Outcomes in nonagenarians undergoing transcatheter aortic valve implantation: a nationwide analysis. EUROINTERVENTION 2020; 15:1489-1496. [PMID: 31763981 DOI: 10.4244/eij-d-19-00647] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to describe the midterm outcomes in nonagenarians undergoing transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS Based on the French administrative hospital discharge database, the study collected information for all consecutive patients with aortic stenosis (AS), and specifically those treated with TAVI between 2010 and 2018. Cox regression was used for the analysis of predictors of events. We compared patients according to their age. Within the studied period, 71,095 patients older than 90 years with AS were identified. After matching on baseline characteristics, TAVI was associated with lower rates of a combined outcome of all-cause death, rehospitalisation for heart failure and stroke (relative risk [RR] 0.58, p<0.001) in comparison with matched nonagenarians with AS treated medically. During follow-up (median 161 days, interquartile range 13-625), the combined outcome occurred more frequently in nonagenarians (RR 1.22, p<0.01) who had a TAVI than in younger patients undergoing this procedure. All-cause death was reported in 17.6% versus 14.5% of nonagenarians, rehospitalisation for heart failure in 21.3% versus 18.2%, and stroke in 3.7% versus 2.9% (p<0.01 for all parameters). We identified the Charlson comorbidity index, heart failure, atrial fibrillation, stroke, vascular disease, cognitive impairment and denutrition as independent predictors of adverse outcomes in nonagenarians undergoing TAVI. CONCLUSIONS Among nonagenarians with AS, patients treated with TAVI had a lower risk of cardiovascular events than matched patients treated medically. The patients undergoing a TAVI at this age were often highly selected; the procedure was associated with acceptable long-term outcomes.
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Elbadawi A, Naqvi SY, Elgendy IY, Almahmoud MF, Hamed M, Abowali H, Ogunbayo GO, Jneid H, Ziada KM. Ethnic and Gender Disparities in the Uptake of Transcatheter Aortic Valve Replacement in the United States. Cardiol Ther 2019; 8:151-155. [PMID: 31240615 PMCID: PMC6828867 DOI: 10.1007/s40119-019-0138-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Little is known about ethnic and gender disparities for transcatheter aortic valve replacement (TAVR) procedures in the United States. METHODS We queried the Nationwide Inpatient Sample (NIS) database (2011-2014) to identify patients who underwent TAVR. We described the temporal trends in the uptake of TAVR procedures among various ethnicities and genders. RESULTS Our analysis identified 39,253 records; 20,497 (52.2%) were men and 18,756 (47.8%) were women. Among all TAVRs, 87.2% were Caucasians, 3.9% were African Americans (AA), 3.7% were Hispanics, and 5.2% were of other ethnicities. We found a significant rise in the trend of TAVRs in all groups: in Caucasian men (coefficient = 0.946, p < 0.001), Caucasian women (coefficient = 0.985, p < 0.001), AA men (coefficient = 0.940, p < 0.001), AA women (coefficient = 0.864, p < 0.001), Hispanic men (coefficient = 0.812, p = 0.001), Hispanic women (coefficient = 0.845, p < 0.001). Hence, the uptrend was most significant among Caucasian women, and relatively least significant among Hispanic men. Multivariate regression analysis was conducted to evaluate in-hospital mortality among different groups after adjusting for demographics and baseline characteristics. After multivariable regression for baseline characteristics overall, the in-hospital mortality per 100 TAVRs was highest among Hispanic men 5.5%, followed by Caucasian women 5.0%, Hispanic women 4.6%, AA women 3.7%, AA men 3.4%, and Caucasian men 3.38% (adjusted p value = 0.004). CONCLUSIONS In this observational study, we demonstrated that there is evidence of ethnic and gender differences in the overall uptake and adjusted mortality of TAVRs in the United States.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Syed Yaseen Naqvi
- Department of Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Mohamed F Almahmoud
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mohamed Hamed
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Hesham Abowali
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
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Kaier K, von Zur Mühlen C, Zirlik A, Bothe W, Hehn P, Zehender M, Bode C, Stachon P. Estimating the additional costs per life saved due to transcatheter aortic valve replacement: a secondary data analysis of electronic health records in Germany. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:625-632. [PMID: 30600467 DOI: 10.1007/s10198-018-1023-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/11/2018] [Indexed: 06/09/2023]
Abstract
Aortic stenosis (AS) is the most common valvular heart disease, with a dismal prognosis when untreated. Recommended therapy is surgical (SAVR) or transcatheter (TAVR) aortic valve replacement. Based on a retrospective cohort of isolated SAVR and TAVR procedures performed in Germany in 2015 (N = 17,826), we examine the impact of treatment selection on in-hospital mortality and total in-hospital costs for a variety of at-risk populations. Since patients were not randomized to the two treatment options, the two endpoints in-hospital mortality and reimbursement are analyzed using logistic and linear regression models with 20 predefined patient characteristics as potential confounders. Incremental cost-effectiveness ratios were calculated as a ratio of the risk-adjusted reimbursement and mortality differences with 95% confidence intervals obtained by Fieller's theorem. Our study shows that TF-TAVR is more costly that SAVR and that cost differences between the procedures vary little between patient groups. Results regarding in-hospital mortality are mixed. SAVR is the predominant procedure among younger patients. For patients older than 85 years or at intermediate and higher pre-operative risk TF-TAVR seems to be the treatment of choice. Incremental cost-effectiveness ratios (ICER) are most favorable for patients older than 85 years (ICER €154,839, 95% CI €89,163-€302,862), followed by patients at higher pre-operative risk (ICER €413,745, 95% CI €258,027-€952,273). A hypothetical shift from SAVR towards TF-TAVR among patients at intermediate pre-operative risk is associated with a less favorable ICER (€1,486,118, 95% CI €764,732-€23,692,323), as the risk-adjusted mortality benefit is relatively small (- 0.97% point), while the additional reimbursement is still eminent (+€14,464). From a German healthcare system payer's perspective, the additional costs per life saved due to TAVR are most favorable for patients older than 85 and/or at higher pre-operative risk.
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Affiliation(s)
- Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79104, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79104, Freiburg, Germany
| | - Andreas Zirlik
- Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79104, Freiburg, Germany
- Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Wolfgang Bothe
- Department of Cardiac and Vascular Surgery, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philip Hehn
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79104, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79104, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79104, Freiburg, Germany.
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Elgendy IY, Mahmoud AN, Elbadawi A, Elgendy AY, Omer MA, Megaly M, Mojadidi MK, Jneid H. In-hospital outcomes of transcatheter versus surgical aortic valve replacement for nonagenarians. Catheter Cardiovasc Interv 2018; 93:989-995. [PMID: 30569661 DOI: 10.1002/ccd.28050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/24/2018] [Accepted: 12/04/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare the in-hospital outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in nonagenarians. BACKGROUND Data comparing the outcomes of TAVR versus SAVR in nonagenarians are limited. METHODS Using the National Inpatient Sample years 2012-2014, hospitalization data were retrieved for subjects aged ≥90 years who underwent TAVR or SAVR for severe aortic stenosis. The incidence of in-hospital mortality and peri-procedural outcomes were compared using unadjusted, multivariate logistic regression, and propensity score matched analyses. RESULTS The final cohort included 6,680 records of nonagenarians undergoing aortic valve replacement, among which 5,840 (87.4%) underwent TAVR. There was no difference in the incidence of in-hospital mortality between both groups in the unadjusted (5.8% versus 6.0% P = 0.95), multivariate (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.35-1.74), and propensity score matched (OR 1.07, 95% CI 0.75-1.51) analyses. In the propensity-matched analysis, TAVR was associated with a lower incidence of acute kidney injury (OR 0.58, 95% CI 0.47-0.72), post-operative blood transfusion (OR 0.51, 95% CI 0.43-0.61), a higher likelihood of discharge to home (OR 4.71, 95% 3.44-5.06), and a similar incidence of pacemaker placement (OR 1.16, 95% 0.89-1.53) and stroke (OR 1.34, 0.90-1.99). CONCLUSIONS In this nationwide analysis, TAVR was associated with an overall similar incidence of in-hospital mortality and less morbidity compared with SAVR. These findings suggest that TAVR is effective and safe in nonagenarians.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Ahmed N Mahmoud
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Ayman Elbadawi
- Department of Medicine, Rochester General Hospital, Rochester, New York
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Mohamed A Omer
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Michael Megaly
- Division of Cardiovascular Medicine, Minneapolis Heart Institute, Abbot Northwestern Hospital, Minneapolis, Minnesota
| | - Mohammad K Mojadidi
- Division of Cardiovascular Medicine, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas
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11
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Tang L, Gössl M, Ahmed A, Garberich R, Bradley SM, Niikura H, Witt D, Pedersen WR, Bae R, Lesser JR, Harris KM, Sun B, Mudy K, Sorajja P. Contemporary Reasons and Clinical Outcomes for Patients With Severe, Symptomatic Aortic Stenosis Not Undergoing Aortic Valve Replacement. Circ Cardiovasc Interv 2018; 11:e007220. [DOI: 10.1161/circinterventions.118.007220] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Liang Tang
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China (L.T.)
| | - Mario Gössl
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Aisha Ahmed
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Ross Garberich
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Steven M. Bradley
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Hiroki Niikura
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Dawn Witt
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Wesley R. Pedersen
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Richard Bae
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - John R. Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Kevin M. Harris
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Benjamin Sun
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Karol Mudy
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
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12
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Ando T, Akintoye E, Holmes AA, Briasoulis A, Pahuja M, Takagi H, Schreiber T, Grines CL, Afonso L. Clinical End Points of Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Patients <65 Years of Age (From the National Inpatient Sample Database). Am J Cardiol 2018; 122:279-283. [PMID: 29880287 DOI: 10.1016/j.amjcard.2018.03.356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/16/2018] [Accepted: 03/21/2018] [Indexed: 11/28/2022]
Abstract
It is unknown if transcatheter aortic valve implantation (TAVI) is a safe alternative to surgical aortic valve replacement (SAVR) in patients <65 years old. Data from the National Inpatient Sample database were utilized. Patients from 2011 to 2015, ages 18 to 64 years old (inclusive) who underwent TAVI and SAVR were included. Patients who underwent SAVR and who also received a concomitant nonaortic valve surgery were excluded. A propensity score analysis was used. A total of 18,970 (528 TAVI and 18,442 SAVR) patients were identified. Patients who underwent TAVI were older (57 ± 7 vs 54 ± 10 years old, p <0.001) with more frequent co-morbidities. Overall in-hospital mortality was similar between TAVI and SAVR (odds ratio [OR] = 0.52, p = 0.12). Postprocedure stroke (OR = 0.50, p = 0.24), acute kidney injury (OR = 0.98, p = 0.89), acute myocardial infarction (OR = 0.48, p = 0.08), and vascular complication requiring surgery (OR = 0.20, p = 0.11) were similar between patients who underwent TAVI and SAVR. Bleeding requiring transfusion (OR = 0.32, p <0.01) was less frequent in patients who underwent TAVI, but new pacemakers (OR = 1.7, p = 0.02) were more frequent in these patients. Patients who underwent TAVI had shorter hospital stays (7.9 vs 10.0 days, p <0.001) and were more likely to be discharged to home. Cost between TAVI and SAVR was similar ($49,014 vs $42,907, respectively, p = 0.82). In the <65 years old patient population, TAVI also conferred similar overall in-hospital mortality compared with patients who underwent SAVR. TAVI resulted in fewer major complications, shorter hospital stay, and more frequent discharge to home, but higher rates of pacemaker implantation compared with SAVR. Therefore, TAVI appears to be a safe alternative to SAVR in patients <65 years old.
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Affiliation(s)
- Tomo Ando
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, Michigan.
| | - Emmanuel Akintoye
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - Anthony A Holmes
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York
| | - Alexandros Briasoulis
- Divison of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa, Iowa
| | - Mohit Pahuja
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Theodore Schreiber
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, Michigan
| | - Cindy L Grines
- Division of Cardiology, North Shore University Hospital, Hofstra Norwell School of Medicine, Manhasset, New York
| | - Luis Afonso
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, Michigan
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13
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Manolis AS, Manolis AA. Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile? Ann Cardiothorac Surg 2017; 6:524-531. [PMID: 29062749 DOI: 10.21037/acs.2017.07.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Antonis A Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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14
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Zegrean M. Never Too Late: A Case Report on Transcatheter Aortic Valve Implantation in a 97-Year-Old Patient. Geriatrics (Basel) 2017; 2:geriatrics2030025. [PMID: 31011035 PMCID: PMC6371167 DOI: 10.3390/geriatrics2030025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/29/2017] [Accepted: 07/12/2017] [Indexed: 11/24/2022] Open
Abstract
Aortic valve stenosis is a well-recognized valvular problem in the aging population. Transcatheter aortic valve implantation (TAVI) is becoming an increasingly popular treatment alternative to surgical aortic valve replacement for frail elderly individuals with symptomatic severe aortic valve stenosis. There are multiple research reports documenting the effectiveness of TAVI in octogenarians; however, few authors discuss the success of this procedure in nonagenarians. This case report depicts the successful transfemoral implantation of a prosthetic aortic valve in a 97-year-old man. Moreover, the current literature on TAVI outcomes in nonagenarians is reviewed.
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