TAVR Readmissions Similar to Surgery’s at 30 Days, but Costs Are Higher

Readmission rates in the first 30 days after aortic valve replacement are similar between patients undergoing surgery or endovascular (transfemoral or transsubclavian) TAVR, but the costs of the transcatheter procedures are about 25% higher, data from a national database show.

To TCTMD, senior study author Deepak L. Bhatt, MD (Brigham and Women’s Hospital), said the similar rate of readmissions is interesting in the context of more and more centers transitioning from SAVR to TAVR. But as the patients were all treated in 2013, he added, there is somewhat of a “data lag” with contemporary practice.

“The procedure has gotten really good in the last few years, even better than when we did this study,” he said. “But I think all attempts to make it even better are warranted, and this was part of that effort to try to provide some granularity around costs and readmissions, and perhaps even more importantly, what those readmissions are.”

While there were a wide range of reasons for readmission, Bhatt noted that “a good chunk of them aren’t directly related to the TAVR.” Endovascular TAVR patients were more likely than surgical patients to be readmitted for chronic obstructive pulmonary disease or respiratory failure, posthemorrhage anemia or GI bleed, and acute cerebrovascular accident or TIA.

Commenting on the research for TCTMD, Ted Feldman, MD (Evanston Hospital, IL), said another part of the message is “that we can do everything we know how to do on the cardiac side, but when we are dealing with older patients with many comorbidities, we still have to face all the other noncardiac issues.”

The data lag is probably most pronounced in the other finding of the study, which was that transapical patients had higher readmission rates than either the transfemoral TAVR or SAVR cohorts.

“It’s best to avoid transapical as much as possible, realizing it won’t always be possible,” Bhatt said. “Transapical, while it can have advantages over conventional open-heart surgery, still carries a lot of the same risks.” The good news, he added, is that newer-generation sheaths are making it possible for more and more patients who previously could not have had a transfemoral procedure to have one.

It’s best to avoid transapical as much as possible, realizing it won’t always be possible. Deepak Bhatt

Feldman said the study is a “look in the rearview mirror” of readmissions and costs during the course of the commercial rollout and amp up of TAVR in the United States. “Just the fact that there were enough apical patients in the analysis to even talk about reflects that this was in a time period lagging significantly behind where we are today,” he said, adding that in terms of alternative access, “apical is at the bottom of the list.”

Led by Avnish Tripathi MD, PhD, MPH (University of Louisville Medical School, Louisville, KY), and published online May 8, 2018, ahead of print in the American Journal of Cardiology, the study assessed 30-day readmissions and costs in 4,682 matched patients from a US database who underwent TAVR (endovascular or transapical) or SAVR in 2013.

Compared with surgery, endovascular TAVR was associated with a shorter median hospital stay, while transapical TAVR stays were similar to those of surgery. Overall, 30-day readmission rates were 16% for transfemoral TAVR and 18% the matched SAVR group (P = 0.188). For patients who underwent transapical TAVR, readmission was 22% compared with 17% in the matched surgical group (P < 0.001).

Grappling With Costs

Cumulative costs (index hospitalization plus costs associated with readmissions within 30 days) were $51,025 for surgery versus $46,756 in the matched endovascular TAVR group (P = 0.03) and $59,575 for surgery versus $45,792 in the matched transapical TAVR group (P < 0.001). Looking at readmission costs alone, though, there were no significant differences between either of the TAVR groups and surgery, suggesting the higher cumulative costs were driven primarily by the price of the TAVR valves, Bhatt said.

In an email, Edward Hannan, PhD (State University of New York, Albany), who was not involved in the study, said it would be useful to have access to surgeon/cardiologist costs in addition to hospital costs, although that was beyond the scope of the readmissions database. He also observed that readmission in the study appeared to be higher among TAVR patients with low propensity-score values.

“With increased use of TAVI, there would be more, not fewer, cases at the low end of the propensity score (people who are now more likely to undergo SAVR), so relative readmissions for TAVI would increase, not decrease,” he suggested.

Feldman said a more contemporary look at the issue would likely reflect some additional decrease in costs among the TAVR groups due to streamlining from general anesthesia to conscious sedation, and less need for ICU stays. SAVR outcomes also are likely to have improved somewhat since 2013, he added, since sicker patients are being more frequently shunted from surgery to TAVR.

“It’s a moving target on both sides of the equation,” Feldman said. “You also have to realize that this is a 30-day comparison, and we all hope that our patients are around for longer than 30 days, so it would be good to know what this analysis looks like at 1 year. Do the differences broaden, or even out? I wouldn’t make a prediction either way.”

Note: Ajay J. Kirtane, MD, who co-authored the study led by Tripathi, is a faculty member of the Cardiovascular Research Foundation, the publisher of TCTMD.