Differential Characteristics and Outcomes of Urgent/Emergent Versus Elective Aortic Valve Replacement

Abstract

Background: Despite the slowly progressive nature of aortic stenosis, a proportion of aortic valve replacements (AVRs) still occur on an urgent/emergent basis. We sought to characterize the predictors, outcomes, and potential opportunities to prevent urgent/emergent AVRs.

Methods: We analyzed Medicare data to identify patients undergoing AVRs from 2017 to 2022. We used multivariable regression to identify factors associated with nonelective AVRs; we also examined the association of nonelective AVRs with clinical outcomes and health care costs.

Results: In total, 15 305 patients (16% urgent/emergent) underwent AVR during the study period. Compared with patients undergoing elective AVRs, those receiving urgent/emergent AVRs were more frequently of Black race or Hispanic ethnicity, and less likely to have received a diagnosis of aortic stenosis, despite 91.7% having seen a cardiologist or primary care provider in the prior year. In multivariable-adjusted analyses, dual Medicare-Medicaid enrollment, male sex, and recent heart failure hospitalization were associated with increased risk for urgent/emergent AVR; conversely, recent aortic stenosis diagnosis and cardiologist visit were associated with lower odds of urgent/emergent AVR. In turn, urgent/emergent compared with elective AVR increased risk for in-hospital death, intensive care unit admission, and discharge to a facility versus home, in addition to longer lengths of stay and higher health care costs.

Conclusions: Urgent/emergent AVR occurs more frequently among Black, Hispanic, and dual Medicare-Medicaid-eligible patients. Nonelective AVR is also associated with worse hospital outcomes as well as greater health care costs. Importantly, variable timing in diagnosis of aortic stenosis appears to be a key determinant; thus, augmented screening efforts may improve outcomes and reduce disparities.

Keywords: Medicare; aortic valve replacement; cardiovascular outcomes; disparities.

Figure 1. Consolidated Standards of Reporting Trials diagram.

AS indicates aortic stenosis; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.

Figure 2. Sociodemographic and clinical characteristics associated with receiving nonelective versus elective aortic valve replacement.

Estimates are derived from a single multivariable logistic regression model adjusting for all the covariates shown. AS indicates aortic stenosis; and AVR, aortic valve replacement.

Figure 3. Association of nonelective aortic valve replacement with index hospitalization outcomes.

Estimates shown are derived from multivariable logistic regression models adjusting for age group, sex, race/ethnicity, Elixhauser Comorbidity Score, dual Medicare–Medicaid enrollment status, census region of residence, rural vs urban hospital location, year of procedure, procedure type (SAVR vs TAVR), and intercepts to account for shared hospital‐level factors (ie, potential clustering effects). ICU indicates intensive care unit; OR, odds ratio; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.