The number of older adults undergoing aortic valve replacement (AVR) has increased by almost 60%, while the rates of mortality, readmission and non-home discharge rates decreased, since the advent of transcatheter aortic valve replacement (TAVR), according to a new analysis of fee-for-service (FFS) Medicare beneficiaries.
Makoto Mori, MD, of the Yale School of Medicine, and colleagues performed the analysis, which was published online Monday and in the Nov. 30 issue of the Journal of American College of Cardiology.
The authors used Centers for Medicare & Medicaid Services (CMS) data to identify FFS Medicare patients who underwent TAVR or surgical aortic valve replacement (SAVR) during an acute-care hospital hospitalization from Jan. 1, 2012, through Dec. 31, 2019. The authors sought to assess changes in baseline characteristics, lengths of stay, hospitalization rates (expressed as per 100,000 beneficiary-years), mortality (30 days, 6 months and 1 year) and readmission rates over time for the patients. Annual change in these outcomes were evaluated by using Cox proportional hazard models.
The key findings of the analysis were:
- Per 100,000 beneficiary-years, there is increase in AVR and TAVR from 107 to 156 and 19 to 101, respectively, while there is a decline in SAVR from 88 to 54.
- The mortality for overall AVR decreased from 11.9% to 9.4% at 1 year, with similar trends in TAVR, from 18.0% to 10.3%, and SAVR, 10.2% to 8.3%.
- The median age remained comparable from 77 years (interquartile range [IQR] 71-83 years) to 78 years (IQR 72-84 years) for overall AVR, whereas a decline was observed, from 84 years (IQR79-88 years) to 81years (IQR 75-86 years) for TAVR, and from 76 years (IQR 71-81 years) to 72 years (IQR 68-77 years) for SAVR.
- The discharge rate to home post-AVR rose from 24.2% to 54.7%, primarily due to increased home discharge post-TAVR, from 28.4% to 69.9%.
- The observance of the contradictory “Will Rogers Phenomenon” among octogenarians, where overall AVR cohort remained relatively unchanged; however, both SAVR and TAVR cohorts became younger with lesser comorbidities.
The authors wrote that these findings suggest that although there is a trend toward an overall migration from SAVR to TAVR, with inclusion of lower-risk patients undergoing TAVR, the SAVR outcomes did not worsen and the overall AVR outcomes continued to improve as a whole.
However, the foremost limitation of this dataset is that it did not represent the contemporary practices as ample number of younger patients (<65 years) undergo AVR because of the study’s focus on Medicare FFS beneficiaries, who are 65 years or older. The findings may not extend to growing cohort of Medicare Advantage beneficiaries and lastly, the analyses did not include the current era of TAVR approval for lower surgical risk patients.
An accompanying editorial by Sreekanth Vemulapalli, MD, of the Duke University School of Medicine, and Vinod H. Thourani, MD, of Piedmont Heart Institute, Atlanta, acknowledged that an important contribution of this analysis is the demonstration of Will Rogers phenomenon, which will help shifting the focus to overall AVR care, instead of head to head comparison of SAVR and TAVR that may cloud the important facts about the evolution of AVR in the United States. The editorialists added that cardiologists and cardiac surgeons, along with their respective societies, should link the Society of Thoracic Surgeons (STS) Cardiac Surgery database and the STS/American College of Cardiology Transcatheter Valve Therapy Registry, along with administrative claims data.
Mori and colleagues concluded that the number of older adults undergoing AVR has substantially increased since the inception of TAVR, while the patient age remained similar with somewhat higher comorbidity profile.
Mori M, Gupta A, Wang Y, et al. Trends in Transcatheter and Surgical Aortic Valve Replacement Among Older Adults in the United States. J Am Coll Cardiol 2021;78:2161–2172.
Vemulapalli S, Thourani VH. Aortic Valve Replacement and Patient-Centered Implementation To Boldly Go Where No Device Has Gone Before. J Am Coll Cardiol 2021;78:2173–2176.
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