Treating Symptomatic Aortic Stenosis With Transcatheter Aortic Valve Replacement: Is There Time to Wait?

Abstract

T he transcatheter aortic valve replacement (TAVR) landscape in the United States has significantly changed over the past 5 years. Not only has the technology improved, but with the approval of TAVR for patients at intermediate risk for surgical aortic valve replacement, the number of patients who are eligible for a TAVR procedure has increased considerably. In 2012, there were 198 sites in the United States performing >4600 TAVR procedures. By 2018, the number of sites had climbed to 580, with >100 000 TAVR procedures performed during the intervening years. In 2015, the annual number of TAVR procedures surpassed the number of surgical aortic valve replacements for the first time. Worldwide, TAVR for treatment of aortic stenosis has an estimated growth of 40% per year. Results of clinical trials further investigating the role of TAVR in low-risk patients and those with asymptomatic severe aortic stenosis are also expected in the coming years. As the number of patients meeting the expanding indications for TAVR continues to grow, the impact of potentially longer wait times may become increasingly important. There is currently no consensus on what an acceptable wait time before TAVR should be. Recent multisociety consensus documents do not address this issue. Some have suggested a maximum wait of 60 days, although this threshold has not been clinically validated. In Canada, a reported median time from referral to TAVR procedure using observational data was 80 days. Despite the large number of TAVR centers in the United States, centers are significantly heterogeneous in terms of procedural volume and expertise. Current wait times for existing programs across the country remain unknown. Factors influencing wait time include availability of local expertise and capacity of medical centers to take increasing volumes of patients. Inefficient coordination of care may also lead to longer wait times, given that TAVR workup requires multiple different outpatient evaluations and testing. To better understand the causes of delay, if any, and the impact of TAVR wait time on outcomes in the United States, it would be highly desirable to have information on wait times and their causes captured in TAVR registries moving forward. In this issue of the Journal of the American Heart Association (JAHA), Wijeysundera and colleagues investigated the impact of wait times on outcomes at 30 days following TAVR. They conducted a retrospective analysis of 2170 patients who received a TAVR procedure between 2010 and 2016 using the TAVR CorHealth Registry data from 10 hospitals in Ontario, Canada. They evaluated whether wait time was associated with increased mortality or hospital readmission within 30 days following a TAVR procedure. Patients who were hospitalized and subsequently underwent TAVR during that admission were considered to have undergone an urgent procedure. In the study, the median time from referral to TAVR procedure was 107 days with an interquartile range of 55 to 176 days. Patients who underwent elective TAVR (80.2% of the cohort) had a median wait time of 124 days (interquartile range: 72–189 days), whereas those who underwent urgent TAVR (19.8%) had a median wait time of 36 days (interquartile range: 14–95 days). Contrary to the authors’ hypothesis, shorter wait times were significantly associated with increased mortality (P<0.001) and 30-day readmission (P=0.01) in unadjusted models; significant associations remained after adjusting for clinical variables. However, they found that when urgency status of TAVR was included in the multivariate model, there was no longer a significant association between wait times and mortality (P=0.58) or 30-day readmission (P=0.98). When patients who underwent urgent and elective TAVR were analyzed as separate groups, the The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (K.F.F., R.W.Y.); Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL (M.-F.P.). Correspondence to: Marie-France Poulin, MD, Rush University Medical Center, Division of Cardiology, 1717 W. Congress Parkway, Suite 313 Kellogg, Chicago IL 60612. Email: [email protected] J Am Heart Assoc. 2019;8:e011527. DOI: 10.1161/JAHA.118.011527. a 2019 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.