Having greater access to transcatheter aortic valve replacement (TAVR) is associated with improved patient outcomes, according to new findings published in the Canadian Journal of Cardiology.[1]
“In many jurisdictions, the demand for TAVR has exceeded capacity, resulting in poor access, with potentially a higher threshold for offering therapy, and/or longer wait-times and substantial wait-time morbidity and mortality,” wrote first author Harindra C. Wijeysundera, MD, PhD, a cardiologist with Sunnybrook Health Sciences Centre in Toronto and the University of Toronto, and colleagues. “These harms must be weighed against possible benefits of centralization, specifically the referral to specialized centers with potentially higher procedural volumes. In other jurisdictions, rapid dissemination of TAVR centers have ensured adequate capacity at a population level, albeit with relatively low volumes at some institutions. Given the relationship between operator/hospital volume and outcomes seen in TAVR, this has raised concerns of poorer post-procedural outcomes being a possible undesirable clinical consequence of more widespread availability of TAVR.”
To learn more about the relationship between TAVR access and TAVR outcomes, Wijeysundera et al. compared data from New York with data from Ontario, Canada. In the state of New York, which has a population of approximately 19 million, TAVR has been available since 2011 and is offered at 36 hospitals. In Ontario, which has a population of approximately 14.8 million, TAVR has been available since 2012 and is offered at 11 hospitals.
The analysis focused on all adult patients from Ontario and New York who underwent TAVR from 2012 to 2018. If patients had multiple procedures, only their initial procedure was included in the study. Patients were also excluded if certain demographic data was unavailable. The primary endpoint was 30-day in-hospital mortality after TAVR, and the secondary endpoint was hospital readmission within 30 days.
A total of 16,814 patients from New York and 5,007 patients from Ontario were included in the team’s analysis. In New York, the median number of TAVR procedures performed per hospital was 268, though it ranged from 1 to 2,559. In Ontario, the median number of TAVR procedures performed per hospital was 528, though it ranged from 13 to 839.
To track patient access over the course of the study, the authors calculated the total number of TAVR procedures performed per 1 million residents. A “dramatic increase” in TAVR access was seen in both New York and Ontario as time went on. In New York, for example, access increased from approximately 32 TAVRs per million in 2012, to approximately 220 TAVRs per million in 2018. In Ontario, access increased from approximately 18 TAVRs per million in 2012, to approximately 87 in 2018.
Overall, 30-day mortality after TAVR was 2.5% in New York and 3.1% in Ontario. The 30-day readmission rate after TAVR was 14.1% in New York and 14.1% in Ontario.
“We found differences in short-term outcomes, specifically that the jurisdiction with higher overall access in terms of TAVR/population had improved outcomes, despite lower volume/hospital on average,” the authors wrote. “Unfortunately, wait-time data for New York State is lacking, but is anticipated to be much shorter than Ontario, given the increased capacity.”
In addition, the authors noted, removing the most urgent TAVR patients from the analysis seemed to cancel out any significant differences between the short-term outcomes of these two populations.
“This suggests that there is potentially a lower threshold to admit patients from the waitlist who are deteriorating and perform an urgent procedure in New York, as compared to Ontario, where due to the lack of capacity, such patients may have died on the waitlist,” the group wrote. “This reinforces the notion that with greater capacity, there is a more liberal approach to patient selection. This hypothesis requires further evaluation, with longer term outcome data beyond 30 days.”
The full study is available here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.