Comorbidity Burden and Adverse Outcomes After Transcatheter Aortic Valve Replacement

Abstract

Background Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for symptomatic patients with aortic stenosis and elevated procedural risk. Many deaths following TAVR are because of noncardiac causes and comorbid disease burden may be a major determinant of postprocedure outcomes. The prevalence of comorbid conditions and associations with outcomes after TAVR has not been studied. Methods and Results This was a retrospective single-center study of patients treated with TAVR from January 2015 to October 2018. The association between 21 chronic conditions and short- and medium-term outcomes was assessed. A total of 341 patients underwent TAVR and had 1-year follow-up. The mean age was 81.4 (SD 8.0) years with a mean Society of Thoracic Surgeons predicted risk of mortality score of 6.7% (SD 4.8). Two hundred twenty (65%) patients had ≥4 chronic conditions present at the time of TAVR. There was modest correlation between Society of Thoracic Surgeons predicted risk of mortality and comorbid disease burden (r=0.32, P<0.001). After adjusting for Society of Thoracic Surgeons predicted risk of mortality, age, and vascular access, each additional comorbid condition was associated with increased rates of 30-day rehospitalizations (odds ratio, 1.21; 95% CI, 1.02-1.44), a composite of 30-day rehospitalization and 30-day mortality (odds ratio, 1.20; 95% CI, 1.02-1.42), and 1-year mortality (odds ratio, 1.29; 95% CI, 1.05-1.59). Conclusions Comorbid disease burden is associated with worse clinical outcomes in high-risk patients treated with TAVR. The risks associated with comorbid disease burden are not adequately captured by standard risk assessment. A systematic assessment of comorbid conditions may improve risk stratification efforts.

Keywords: cardiac disease; cardiovascular disease risk factors; clinical cardiology; transcatheter aortic valve implantation.

Figure 1. Distribution of comorbid disease count: a graphic representation of comorbid disease among the studied population.

The average number of comorbid conditions present in the year leading up to TAVR was 4.4 (SD 1.9). TAVR indicates transcatheter aortic valve replacement.

Figure 2. STS‐PROM vs comorbidity count: a graphic representation of STS‐PROM plotted against comorbid disease burden.

Q1 identifies a STS‐PROM score ≥4.0% and high comorbidity burden (≥4 comorbid conditions), which represents 166 patients (49%) from the studied population. Q2 represents a STS‐PROM score ≥4.0% and low comorbidity burden (<4 comorbid conditions), which represents 65 patients (19%) from the studied population. Q3 represents a STS‐PROM score <4.0% and low comorbidity burden (<4 comorbid conditions), which represents 56 patients (16%) from the studied population. Q4 highlights a STS‐PROM score <4.0% and high comorbidity burden (>4 comorbid conditions), which represents 54 patients (16%) from the studied population. STS‐PROM indicates Society of Thoracic Surgeons predicted risk of mortality.