Urgent vs Elective Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis

Abstract

Background: Urgent transcatheter aortic valve replacement (TAVR) is increasingly performed for acutely decompensated aortic stenosis, but outcome data remain limited, particularly in contemporary lower-risk populations.

Objectives: This study aimed to compare characteristics, procedural success, and outcomes among patients undergoing urgent vs elective TAVR.

Methods: Consecutive patients who underwent TAVR at 2 high-volume centers between 2017 and 2023 were included. The primary outcome was 30-day mortality. Secondary outcomes included procedural success, in-hospital complications, and postdischarge outcomes at 30 days and 12 months.

Results: Of 1,414 patients undergoing TAVR, 127 (9.0%) underwent urgent procedures (median Society of Thoracic Surgeons Predicted Risk of Mortality score 3.3 [Q1-Q3: 2.0-5.0]). Compared to elective cases, urgent TAVR patients were younger, more likely to reside in regional or socioeconomically disadvantaged areas, and exhibited more severe valve stenosis with greater cardiac remodeling. Procedural success and post-TAVR valve function were similar between groups. However, urgent TAVR was associated with higher rates of acute kidney injury (9.2% vs 3.4%, P = 0.002), 30-day mortality (2.9% vs 0.8%, P = 0.04), and 12-month mortality (14.3% vs 5.3%, P = 0.02). After multivariable adjustment, 30-day mortality differences were no longer significant, but urgent TAVR remained independently associated with increased acute kidney injury (adjusted OR: 2.43; 95% CI: 1.17-5.05; P = 0.017) and 12-month mortality (adjusted HR: 3.18; 95% CI: 1.06-9.54; P = 0.04).

Conclusions: In this low-intermediate risk cohort, urgent TAVR offered comparable procedural success and adjusted 30-day mortality to elective TAVR but was associated with higher 12-month mortality. These findings support urgent TAVR as a feasible short-term intervention while highlighting the need for targeted strategies to optimize long-term outcomes in high-risk populations.

Keywords: aortic stenosis; cardiac remodeling; mortality; outcomes; transcatheter aortic valve replacement; urgent TAVR.

Graphical abstract

Central Illustration

Outcomes of Urgent vs Elective Transcatheter Aortic Valve Replacement Compared with patients undergoing elective TAVR, those undergoing urgent TAVR presented with more severe aortic stenosis, greater adverse cardiac remodeling, higher symptom burden, and reduced quality of life. Urgent TAVR patients were more likely to reside in regional or rural areas and to be from lower socioeconomic backgrounds. Although procedural success rates were comparable between groups, urgent TAVR was associated with a higher incidence of postprocedural AKI and increased 30-day and 12-month mortality. The 12-month mortality remained significantly higher in the urgent TAVR group after multivariable adjustment. Other device-related and in-hospital complications did not differ significantly between groups. AKI = acute kidney injury; AS = aortic stenosis; CKD = chronic kidney disease; SES = socioeconomic status; other abbreviations as in Figure 2.

Figure 1

Trends in the Proportion of Urgent Transcatheter Aortic Valve Replacements From 2017 to 2023 The bar chart represents the total number of TAVR procedures (blue) and the number of urgent TAVRs (red) performed each year. The dashed line indicates the percentage of TAVRs performed urgently. TAVR = transcatheter aortic valve replacement.

Figure 2

Unadjusted and Adjusted 12-Month Mortality After Transcatheter Aortic Valve Replacement, Stratified by Urgency Status The left panel shows unadjusted Kaplan-Meier estimates with numbers at risk. The right panel shows adjusted mortality curves derived from Cox proportional hazards models with adjustments for age, gender, Society of Thoracic Surgeons Predicted Risk of Mortality Score, chronic kidney disease, aortic valve area, left ventricular ejection fraction, left ventricular mass index, significant mitral regurgitation, and access route. To generate adjusted curves, continuous variables were set at the sample mean (age = 80.5 years, STS-PROM = 4.17, aortic valve area = 0.81, LV mass index = 108.92), while categorical variables were fixed at their modal value (male sex, no prior CKD, no significant MR, and transfemoral access) to represent a typical patient in the sample. Both analyses demonstrate higher mortality in urgent compared to elective TAVR procedures over 12 months of follow-up. HRs and aHRs with 95% CIs derived from Cox models are presented. aHR = adjusted HR; CKD = chronic kidney disease; LV = left ventricular; MR = mitral regurgitation; STS-PROM = Society of Thoracic Surgeons Predicted Risk of Mortality; TAVR = transcatheter aortic valve replacement.