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Impact of postdischarge care fragmentation on clinical outcomes and survival following transcatheter aortic valve replacement

Auswirkung der Fragmentierung der Nachsorge nach der Entlassung auf die klinischen Ergebnisse und das Überleben nach einem Transkatheter-Aortenklappenersatz

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Abstract

Background

The study aimed to evaluate the prognostic impact of postdischarge care fragmentation in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

A total of 266 patients undergoing TAVR due to severe aortic stenosis were included in this retrospective cohort study. Patients were assigned to one of two groups based on presence (n = 104) and absence (n = 162) of postdischarge care fragmentation. Fragmented care was defined as at least one readmission to a site other than the implanting TAVR center within 90 days. Prognostic impact of care fragmentation on clinical outcomes and predictors of long-term mortality were investigated.

Results

Increased major vascular complication (16.3 vs 8.0%, p = 0.037), permanent pacemaker implantation (14.4 vs 6.2%, p = 0.025), and acute kidney injury (22.1 vs 14.2%, p < 0.001) were reported in the fragmented care group. Although early mortality (6.7 vs 4.3%, p = 0.152) was similar between groups, there was a significant difference in 5‑year mortality (66.3 vs 45.7%, p < 0.001). In a univariate regression analysis fragmented care, age, chronic obstructive pulmonary disease, pulmonary artery systolic pressure, and paravalvular leakage were significantly associated with 5‑year mortality. Fragmented care (hazard ratio [HR] 1.510, 95% confidence interval [CI] 1.080–2.111; p = 0.016), age (HR 1.024, 95% CI 1.001–1.048; p = 0.045), paravalvular leakage (HR 1.863, 95% CI 1.076–3.228; p = 0.026), and chronic obstructive pulmonary disease (HR 1.616, 95% CI 1.114–2.344; p = 0.012) were found to be significant independent predictors of 5‑year mortality in a multivariate analysis, after adjusting for other risks.

Conclusion

Fragmented care has a significant prognostic impact on clinical outcomes and survival.

Zusammenfassung

Hintergrund

Ziel der Studie war es, die prognostischen Auswirkungen der Fragmentierung der Nachsorge bei Patienten zu untersuchen, die sich einem transkathetergestützten Aortenklappenersatz (TAVR) unterziehen.

Methoden

Insgesamt 266 Patienten, die sich aufgrund einer schweren Aortenstenose einer TAVR unterzogen haben, wurden in diese retrospektive Kohortenstudie eingeschlossen. Die Patienten wurden aufgrund des Vorhandenseins (n = 104) und des Fehlens (n = 162) einer Fragmentierung der Betreuung nach der Entlassung in 2 Gruppen eingeteilt. Fragmentierte Versorgung wurde definiert als mindestens eine Wiederaufnahme an einem anderen Ort als dem implantierenden TAVR-Zentrum innerhalb von 90 Tagen. Die prognostischen Auswirkungen der Fragmentierung der Versorgung auf die klinischen Ergebnisse und die Prädiktoren der Langzeitmortalität wurden untersucht.

Ergebnisse

In der Gruppe mit fragmentierter Versorgung wurde über eine erhöhte Anzahl schwerer vaskulärer Komplikationen (16,3 vs. 8,0%, p = 0,037), die Implantation eines permanenten Schrittmachers (14,4 vs. 6,2%, p = 0,025) und eine akute Nierenverletzung (22,1 vs. 14,2%; p < 0,001) berichtet. Obwohl die frühe Mortalität (6,7 vs. 4,3%; p = 0,152) zwischen den Gruppen ähnlich war, gab es einen signifikanten Unterschied in der 5‑Jahres-Mortalität (66,3 vs. 45,7%, p < 0,001). In einer univariaten Regressionsanalyse waren fragmentierte Versorgung, Alter, chronisch-obstruktive Lungenerkrankung, systolischer Druck in den Lungenarterien und paravalvuläre Lecks signifikant mit der 5‑Jahres-Mortalität assoziiert. Die fragmentierte Versorgung (Hazard-Ratio [HR] 1,510; 95% Konfidenzintervall [KI] 1,080–2,111; p = 0,016), das Alter (HR 1,024; 95% KI 1,001–1,048; p = 0,045), paravalvuläre Lecks (HR 1,863; 95% KI 1,076‑3,228; p = 0,026) und eine chronisch-obstruktive Lungenerkrankung (HR 1,616; 95% KI 1,114–2,344; p = 0,012) erwiesen sich in einer multivariaten Analyse nach Bereinigung um andere Risiken als signifikante unabhängige Prädiktoren für die 5‑Jahres-Mortalität.

Schlussfolgerung

Die fragmentierte Versorgung hat einen signifikanten prognostischen Einfluss auf die klinischen Ergebnisse und das Überleben.

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Faculty of Medicine, Department of Cardiology, Bezmialem Foundation University, Adnan Menderes Avenue, Vatan Street, 34093, Fatih/Istanbul, Turkey

    E. Karacop MD, A. Enhos MD & N. Bakhshaliyev MD

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  1. E. Karacop MD
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  2. A. Enhos MD
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  3. N. Bakhshaliyev MD
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Correspondence to E. Karacop MD.

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Conflict of interest

E. Karacop, A. Enhos and N. Bakhshaliyev declare that they have no competing interests. The authors alone are responsible for the content and writing of the paper. The authors have had full control of all primary data and they agree to allow the journal to review their data if requested.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Karacop, E., Enhos, A. & Bakhshaliyev, N. Impact of postdischarge care fragmentation on clinical outcomes and survival following transcatheter aortic valve replacement. Herz 46 (Suppl 2), 180–186 (2021). https://doi.org/10.1007/s00059-020-04976-2

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  • DOI: https://doi.org/10.1007/s00059-020-04976-2

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