Search

Background: Transcatheter aortic valve replacement (TAVR) has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR among jurisdictions. It is unknown if such variation is associated with differences in postprocedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high vs low access of care to TAVR translate to differences in postprocedural outcomes., Methods: In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1, 2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all-cause readmissions. Using indirect standardization, we calculated the observed vs expected outcomes for New York patients, had they been treated in Ontario., Results: Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5% of New York patients. With adjustment, this translated to an observed-expected ratio of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients., Conclusions: Having greater access to TAVR may be associated with improved outcomes, potentially because of intervention earlier in the trajectory of the disease., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Importance: The optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease., Objective: To compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study., Design, Setting, and Participants: This multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019., Exposures: Total arterial revascularization., Main Outcomes and Measures: Primary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome., Results: Of 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization., Conclusions and Relevance: Total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.

Objectives: The aim of this study was to assess the impact of individual operator experience on transfemoral transcatheter aortic valve replacement (TAVR) outcomes., Background: TAVR volume-outcome relationships have not been evaluated at the individual operator level., Methods: New York Statewide Planning and Research Cooperative System data from 8,771 transfemoral TAVR procedures performed by 207 operators between 2012 and 2016 were analyzed. Operator volume was defined as the number of TAVR procedures performed during 1 year prior to the index procedure. Hierarchical and restrictive cubic spline regression models were used to evaluate the impact of individual operator experience on risk-adjusted in-hospital outcomes. The primary outcome was a composite of in-hospital mortality, stroke, and/or acute myocardial infarction. Secondary outcomes were the individual components of the primary outcome., Results: After adjusting for hospital and physician characteristics, patients undergoing TAVR performed by high-volume physicians (≥80/year) had a significantly lower risk for death, stroke, or acute myocardial infarction (odds ratio: 0.59; 95% confidence interval: 0.37 to 0.93) compared with those treated by low-volume physicians (<24/year). Being treated by operators who performed 200 procedures during the prior year was associated with significantly lower risks for post-procedural stroke (odds ratio: 0.41; 95% confidence interval: 0.17 to 0.97) and composite events (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78). This relationship was nonlinear, and a sensitivity analysis excluding the first 10, 20, and 30 procedures for each operator mitigated the effect of the initial learning curve., Conclusions: Increased TAVR experience of operators is associated with improved risk-adjusted in-hospital outcomes. These results have potentially important implications for individual training and hospital programs in TAVR., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)