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Identifying patients likely to be readmitted after transcatheter aortic valve replacement
  1. Andrew Goldsweig1,
  2. Herbert David Aronow2,3
  1. 1 Department of Cardiovascular Medicine, University of Nebraska Medical Center College of Medicine, Omaha, Nebraska, USA
  2. 2 Department of Cardiovascular Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
  3. 3 Cardiovascular Institute, Lifespan Health System, Providence, Rhode Island, USA
  1. Correspondence to Dr Andrew Goldsweig, Cardiovascular Medicine, University of Nebraska Medical Center College of Medicine, Omaha, Nebraska, USA; andrew.goldsweig{at}unmc.edu

Abstract

Hospital readmission following transcatheter aortic valve replacement (TAVR) contributes considerably to the costs of care. Readmission rates following TAVR have been reported to be as high as 17.4% at 30 days and 53.2% at 1 year. Patient and procedural factors predict an increased likelihood of readmission including non-transfemoral access, acute and chronic kidney impairment, chronic lung disease, left ventricular systolic dysfunction, atrial fibrillation, major bleeding and prolonged index hospitalisation. Recent studies have also found the requirement for new pacemaker implantation and the severity of paravalvular aortic regurgitation and tricuspid regurgitation to be novel predictors of readmission. Post-TAVR readmission within 30 days of discharge is more likely to occur for non-cardiac than cardiac pathology, although readmission for cardiac causes, especially heart failure, predicts higher mortality than readmission for non-cardiac causes. To combat the risk of readmission and associated mortality, the routine practice of calculating and considering readmission risk should be adopted by the heart team. Furthermore, because most readmissions following TAVR occur for non-cardiac reasons, more holistic approaches to readmission prevention are necessary. Familiarity with the most common predictors and causes of readmission should guide the development of initiatives to address these conditions proactively.

  • transcatheter valve interventions
  • aortic stenosis
  • health care delivery
  • quality and outcomes of care

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Introduction

Health systems and government agencies devote a tremendous amount of resources to reducing hospital readmission both because readmission may indicate poor quality of care and because readmission contributes to the cost of care considerably. In the USA, the Center for Medicare and Medicaid Services has established readmission as a quality metric that affects reimbursement. Transcatheter aortic valve replacement (TAVR) is a particularly expensive procedure often performed in elderly patients with multiple comorbidities. While the likelihood of short-term procedural success is high, so is the long-term risk of readmission. This review discusses the rates, predictors, causes and outcomes of readmission following TAVR as well as efforts to address these issues. It is hoped that further research in this domain will result in lower readmission rates and improved outcomes for readmitted patients.

Rate of post-TAVR readmission

Three large national registries provide representative statistics for readmission following TAVR. In the USA, the National Cardiovascular Data Registry (NCDR) Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry, the world’s largest source of post-TAVR data, records inpatient readmission at two timepoints, 30 days and 1 year post-TAVR.1 A 2015 TVT Registry analysis reported 30-day and 1-year readmission rates of 17.4% and 53.2%, respectively.2 The French Aortic National Corevalve and Edwards (FRANCE-2) Registry, which contains records from more than 4200 procedures in that country, collects inpatient readmission data at 30 days, 6 months and annually for 5 years.3 This Registry has published all-cause annual readmission rates of 28%, 22%, and 26%, respectively, during the first 3 years following TAVR. In Japan, the eight-centre Optimised transCathEter vAlvular interveNtion Transcathater Aortic Valve Implantation (OCEAN-TAVI) Registry records precise inpatient readmission dates.4 Of 1215 patients, only 3.5% of patients were readmitted within 30 days and 18.4% were readmitted within 1 year. Of note, a single-centre 2019 study found no significant difference between TAVR and surgical aortic valve replacement in 30-day, 1-year and 5-year readmission rates.5

Predictors of post-TAVR readmission

Box 1 summarises the most significant predictors of post-TAVR readmission, and table 1 highlights the data confirming these predictors. Frequently identified predictors include non-transfemoral valve delivery, acute and chronic kidney impairment, chronic lung disease, left ventricular systolic dysfunction, atrial fibrillation (AF), major bleeding and prolonged index hospitalisation.

Box 1

Summary of patient and procedural factors predictive of post-TAVR readmission

Patient factors

  • Female sex.

  • >1 admission in year pre-TAVR.

  • Anaemia.

  • Hypoalbuminaemia.

  • Diabetes.

  • Chronic kidney disease.

  • Chronic lung disease.

  • Chronic liver disease.

  • Atrial fibrillation.

  • Low LVEF.

  • Previous myocardial infarction.

  • Home oxygen.

  • Decreased 5 m gait speed.

  • ≥Moderate aortic or mitral regurgitation.

  • Peripheral vascular disease.

  • Increased STS PROM score.

Procedural factors

  • Non-teaching hospital.

  • Non-transfemoral TAVR.

  • Acute kidney injury.

  • Vascular complication.

  • Major bleeding.

  • Index admission ≥5 days.

  • Antiplatelet+anticoagulation therapy at discharge.

  • Discharge disposition.

LVEF, left ventricular ejection fraction; STS PROM, Society of Thoracic Surgeons Predicted Risk of Mortality; TAVR, transcatheter aortic valve replacement.

Table 1

Selected major studies of post-TAVR readmission

In general, for patients undergoing ‘alternative access’ TAVR or non-transfemoral valve delivery, although index hospitalisations are longer, readmission rates have not been significantly higher, as demonstrated in a study of transfemoral, trans carotid and transcaval patients at a single, high-volume US centre.6 This finding of similar readmission rates for alternative access patients was confirmed for patients of mean age 82–85 years old with and without peripheral artery disease, the principal indication for alternative access, in the NCDR STS/ACC TVT Registry.7 Conversely, in separate, much smaller studies of nonagenarians, alternative access resulted in a 30-day readmission rates of 32%–58% versus 16%–24% following transfemoral access,8 9 suggesting that elderly, frail patients may be more susceptible to the ill-effects of non-transfemoral TAVR than their younger, more robust counterparts.

Both acute kidney injury (AKI) and chronic kidney disease (CKD) have been associated with post-TAVR readmission. In an analysis of the Nationwide Readmissions Database (NRD), AKI was associated with an OR of 1.23 (95% CI 1.05 to 1.44) for 30-day readmission, and CKD with an OR of 1.20 (95% CI 1.04 to 1.39). In another NRD study, end-stage renal disease (ESRD) was associated with an OR of 2.11 (95% CI 1.7 to 2.63) for 30-day readmission10; one study of 43 patients with ESRD reported a 30-day readmission rate of 18.9%.11

Eight of the largest studies of post-TAVR readmission have identified chronic lung disease as a significant predictor, the single most congruent predictor among the various studies in this field.2 10 12–17 However, TAVR clearly benefits these patients: in a randomised controlled trial of 131 patients with severe chronic obstructive pulmonary disease (COPD) as defined by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease criteria,18 patients undergoing TAVR had a 14.8% rate of 30-day heart failure readmission compared with 43% in patients receiving medical management (p=0.016), and 3-year mortality followed the same trend, occurring in 51.8% and 87% (p<0.0001) of patients, respectively.19

Left ventricular ejection fraction (LVEF) is negatively correlated with the likelihood of readmission. Each 1% decrease in LVEF at hospital discharge had an HR of 1.08 (95% CI 1.0 to 1.17) for readmission at 30 days.17 At 1-year post-TAVR, for LVEFs of >45%, 30%–45% and <30%, the mean number of days alive and out of the hospital were 295, 284 and 270, respectively.2

AF or flutter predicts readmission following TAVR. A pre-TAVR diagnosis of AF has been associated with increased 30-day10 12 17 20 and 1-year readmission17 compared with patients without antecedent AF. Data from 48 715 TAVR hospitalisations in the Nationwide Inpatient Sample documented new-onset AF in 50.4% of patients without prior AF who were admitted for TAVR and related new-onset AF to increased in-hospital mortality, stroke, and length of stay.21 The effect of new-onset AF on readmission has not yet been characterised.

Bleeding and vascular complications during the index hospitalisation predict readmissions following TAVR. Periprocedural major or life-threatening bleeding, as defined by the Valve Academic Research Consortium II criteria,22 increased 30-day readmission with a HR 2.41 (95% CI 1.57 to 3.70).17 In contrast, in-hospital life-threatening bleeding was not associated with 1-year readmission post-TAVR, with an HR 1.40 (95% CI 0.89 to 2.19).23

Longer index hospitalisation length of stay has generally been associated with higher rates of 30-day readmission,10 12 16 although one study found no association at 30 days (p=0.92) but a significant association at 1 year (p=0.01).24

Other emerging predictors include new pacemaker requirement, paravalvular aortic regurgitation and tricuspid regurgitation (TR). Patients undergoing new pacemaker implantation following TAVR have a 30-day heart failure readmission rate of 22.4% compared with 16.1% for patients without a new pacemaker.13 For patients enrolled in the Placement of AoRTic TraNscathetER Valves (PARTNER II) trial, TAVR patients with moderate or greater paravalvular aortic regurgitation had an HR of 2.27 (95% CI 1.31 to 3.94) for 1-year readmission compared with patients with mild or no paravalvular regurgitation.25 A single study confirmed the relationship between moderate or greater pre-TAVR TR and 30-day readmission.26 For patients with severe TR and LVEF >30%, a TVT Registry analysis reported an HR of 1.27 (95% CI 1.04 to 1.54) for 1-year heart failure readmission,27 and a multicentre Spanish study linked moderate or greater TR, but not moderate or less mitral regurgitation, to increased 6-month mortality.28

Finally, data have been mixed regarding the association between gender and post-TAVR readmission. Some studies have shown a positive association with female gender,2 15 while others have not.29

Causes of post-TAVR readmission

Post-TAVR readmission within 30 days of discharge is more likely to occur for non-cardiac than for cardiac causes, with 54%–65% of admissions occurring for the former.15–17 23 Among non-cardiac causes, respiratory, infectious, bleeding and vascular conditions have been identified as the most common causes of 30-day readmission.16 Congestive heart failure and arrhythmias were the most common cardiac causes of 30-day readmission.15 One-year follow-up data suggest that early readmissions are often procedure related and late readmissions are more often related to baseline comorbidities.17

Outcomes of post-TAVR readmission

Not surprisingly, readmission following TAVR has been associated with increased mortality. One study found an adjusted HR of 1.89 for 2-year mortality for patients with versus without 30-day readmissions.17 Readmission for cardiac causes, and especially for heart failure,14 predicted higher post-TAVR mortality than readmission for non-cardiac causes.30 Furthermore, 30-day readmission post-TAVR resulted in a 26% increase in cumulative costs.31

Addressing post-TAVR readmission

Interdisciplinary, multisociety guidelines recommend incorporation of frailty and comorbidity assessment into preprocedural planning to avoid medical futility as well as to establish realistic expectations for patients and their families.32 In 2016, Puri et al 33 comprehensively reviewed the issue of futility with respect to post-TAVR mortality, highlighting poor post-TAVR survival related both to non-cardiac conditions (severe chronic lung disease, chronic kidney disease and frailty) as well as cardiovascular conditions (reduced LVEF or reduced stroke volume, pulmonary hypertension and severe mitral regurgitation). A risk score based on the FRANCE-2 Registry has been published to address futility based on predicted 30-day mortality,34 and a model from the PARTNER trial encompasses both mortality and quality of life outcomes.35

While readmission may predict mortality, the two phenomena are fundamentally distinct. Separate from mortality, physicians must account for the risk of readmission when selecting appropriate patients for TAVR, planning procedures and optimising patients’ pre-TAVR health status. Recently, Khera et al published a tool to facilitate the prediction of a patient’s 30-day readmission risk.10 Just as Society of Thoracic Surgeons Predicted Risk of Mortality and/or EuroScore calculation has become a standard part of pre-TAVR work-up, the routine calculation and consideration of readmission risk might also be adopted by the heart team.

Beyond careful selection of appropriate patients for TAVR, strategies to combat readmission will require further development and evaluation. The modifiable factors among the predictors listed in Box 1 should be medically optimised: anaemia may be corrected with transfusion and iron supplementation, and maximal therapy to control diabetes, AF and kidney, liver and lung diseases should be instituted prior to TAVR. Pharmacologically, prescription of a renin-angiotensin system (RAS) inhibitor has been show in a TVT Registry analysis to decrease 1-year heart failure readmission following TAVR (HR 0.86, 95% CI 0.79 to 0.95), regardless of LVEF (p=0.84 for interaction) or renal function (p=0.42 for interaction)36; the association of RAS inhibition with reduced readmission has also been shown in a prospective observational 10-centre study37 and is the subject of a single-arm prospective clinical trial (RASTAVI, NCT03201185). Because impaired pre-TAVR functional capacity, as typified by slow gait speed, and nutrition, as typified by hypoalbuminaemia, are associated with readmission, preprocedure physical therapy (‘prehab’) and protein supplementation may also reduce readmission; the randomised Protein and Exercise to Reverse Frailty in OldeR Men and women undergoing Transcatheter Aortic Valve Replacement (PERFORM-TAVR) trial (NCT03522454) is currently testing this hypothesis. Procedurally, of the identified predictors of readmission, AKI may be reduced with decreased contrast volume and prehydration,38 pacemaker implantation may be reduced with shallower depth of valve implantation,39 paravalvular leak may be reduced with postdilation40 and bleeding may be minimised with diligent attention to procedural technique including ultrasound-guided femoral arterial access.41

Recently, the Center for Medicare and Medicaid Services’ Hospital Readmission Reduction Program has received considerable attention for its association with reduced readmission but increased mortality for patients admitted with heart failure, acute myocardial infarction or pneumonia.42 The fundamental flaw in this programme is its narrow scope, focusing solely on readmission related to the index admission diagnosis. Similarly, because most readmissions following TAVR occur for non-cardiac reasons, more holistic approaches to readmission prevention are necessary. Such approaches will need to address patients’ diverse healthcare needs proactively by including regularly scheduled well visits with primary care, cardiovascular and other specialty service providers as indicated by each individual’s medical needs.

Conclusion

Hospital readmission following TAVR is common, predictable and potentially preventable. Poor outcomes for patients readmitted post-TAVR argue strongly for the importance of appropriately selecting patients who are likely to benefit from TAVR because frailty and non-cardiac comorbidities—not cardiac issues—are responsible for the majority of post-TAVR readmission and related morbidity and mortality. Assessment for the most common predictors and causes of readmission may guide the development and implementation of initiatives to address these conditions proactively and preemptively. Rather than continuing to round up the usual suspects for readmission after TAVR—patients with conditions predisposing them to readmission—the structural heart disease community must ensure that TAVR patients are carefully vetted and receive comprehensive postprocedure care to keep them healthy at home.

References

Footnotes

  • Twitter @agoldsweig, @herbaronowMD

  • Contributors Both authors participated in the writing of this review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.