Urgent TAVRs have comparable success rates to elective procedures but are associated with higher 12-month mortality, an analysis of Victorian patients has found.
The study, published in JACC: Advances, also found patients undergoing urgent TAVR procedures were younger, more likely to come from lower socioeconomic status or from regional areas, and had more severe valve stenosis and greater cardiac remodelling at the time of their surgeries [link here].
The Melbourne-based research team reviewed outcomes from 1,414 patients undergoing TAVR in high-volume centres between 2017 and 2023, 9% of which had urgent surgeries.
They found procedural success and improvements in post-TAVR valve parameters were similar between urgent and elective cases, but urgent surgeries were associated with higher 30-day mortality (2.9% vs 0.8%), 12-month mortality (14.3% vs 5.3%) and rates of acute kidney injury (9.2% vs 3.4%).
The differences in 30-day mortality were no longer significant after adjustment for baseline characteristics, but urgent procedures remained an independent predictor for acute kidney injury and increased mortality at 12 months.
Professor Dion Stub was one of the study’s authors.
The authors, who included Professor Dion Stub and Dr Jennifer Zhou at Melbourne’s Alfred Health, said their findings showed TAVR was “a feasible option for patients requiring expedited intervention, offering acceptable procedural and short-term outcomes”.
However, the data also underscored the importance of timely intervention in severe aortic stenosis, given the extent of adverse cardiac remodeling seen in the urgent group.
“The presence of multiple adverse remodeling features in the urgent TAVR cohort suggests that these patients presented at a late stage of disease, contributing to their worse outcomes despite similar postprocedural valve function,” they wrote.
“The higher long-term mortality observed in urgent cases likely reflects the consequences of delayed presentation and irreversible myocardial damage rather than procedural risk alone.”
Selection bias may have played a role in the number of urgent patients from regional and remote areas, the authors said.
Despite this, the findings could also reflect broader inequalities in healthcare access, they wrote.
“Delayed AS diagnosis and referral in these populations may stem from reduced access to primary care, longer specialist wait times, and barriers to health care engagement, including lower health literacy and financial constraints.”
Previous research by the group had found lower SES patients were associated with longer workup and procedural wait times when compared with patients in the group of highest socioeconomic advantage [link here].
More data needed on urgency status
Responding to the paper, University of Athens interventional cardiology researcher Dr Nikolaos Pyrpyris and colleagues wrote that more information was needed on the indications for urgent TAVRs in the study.
“Despite the elaborately described cohort, the authors do not note the indications for the urgent procedure (ie, cardiogenic shock and decompensated heart failure), as well as the timing of urgent TAVR in regard to symptom onset,” they wrote in a letter to the editor of JACC: Advances [link here].
“Further describing the baseline patient status based on established scores is crucial, in order to evaluate differences in patients with different urgency or shock severity and therefore establish TAVR utility or futility.”
In response, Professor Stub and Dr Zhou agreed more details on the need for urgent TAVR were important, although they stressed these were not available for the cohort in the study.
“Our findings, however, do underscore the importance of routinely documenting urgency status and the indication for urgent procedures in structural heart registries,” they said.
“Given that urgent TAVR accounted for nearly 1 in 10 cases in our cohort and was associated with poor outcomes, systematic collection of these data would improve understanding, enable benchmarking across centers, and inform future research in this high-risk yet common scenario.”