Long-Term Prognostic Value of the Society of Thoracic Surgery Risk Score in Patients Undergoing Transcatheter Aortic Valve Implantation (From the OCEAN-TAVI Registry)

doi:10.1016/j.amjcard.2021.03.027

The American Journal of Cardiology

Volume 149, 15 June 2021, Pages 86-94

https://doi.org/10.1016/j.amjcard.2021.03.027 Get rights and content

Highlights

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The STS score was designed to predict 30-day mortality after cardiac surgery.
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Lower mortality after transcatheter aortic valve implantation than was predicted.
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High STS score is associated with an increased risk of long-term mortality.
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Similar long-term mortality in patients with low and intermediate scores.

The Society of Thoracic Surgeons (STS) risk model, designed to predict operative mortality after cardiac surgery, is often used for the risk assessment of patients considered for transcatheter aortic valve implantation (TAVI). We investigated the long-term prognostic value of the STS score by utilizing the data of 2588 patients undergoing TAVI from the OCEAN (Optimized CathEter vAlvular iNtervention)—TAVI Japanese multicenter registry. The patients were divided into 3 groups according to their pre-procedural STS score as follows: low-risk (STS score <4%, n = 467 [18%]), intermediate-risk (4%≤ STS score <8%, n = 1200 [46.4%]), and high-risk (8%≤ STS score, n = 921 [35.6%]). Low-risk patients were younger and were more frequently male. The prevalence of most of the comorbidities were higher in high-risk patients, while active cancer was more frequent in low-risk patients (p <0.001).The cumulative 4-year all-cause mortality rates were higher in high-risk patients (49.0%) but comparable in low-risk (22.6%) and intermediate-risk patients (28.7%) (hazard ratio [HR] for intermediate-risk versus low-risk, 1.03; 95% confidence interval [CI], 0.77 to 1.37; p = 0.85; HR for high-risk versus low-risk, 2.27; 95% CI 1.72 to 2.99; p = <0.001). Similarly, the cumulative 4-year cardiovascular mortality rates were higher in high-risk patients (20.5%) but comparable in low-risk (9.9%) and intermediate-risk patients (10.3%) (HR for intermediate-risk versus low-risk, 1.10; 95% CI, 0.68 to 1.77; p = 0.69; HR for high-risk versus low-risk, 2.33; 95% CI 1.48 to 3.67; p = <0.001). After adjustment for several confounders, STS score ≥8% was independently associated with increased long-term mortality (HR, 1.35; 95% CI, 1.08 to 1.68). In conclusion, the risk stratification according to STS score demonstrated an increased risk of long-term mortality after TAVI in high-risk patients, albeit with comparable risks in intermediate- and low-risk patients.

Section snippets

Methods

We evaluated the data of 2588 patients with severe AS who underwent TAVI that were available from the OCEAN-TAVI (Optimized CathEter vAlvular iNtervention—Transcatheter Aortic Valve Implantation) registry. The OCEAN-TAVI registry is an ongoing, prospective, multicenter TAVI registry, from which the current data include information from 14 institutions in Japan reported between October 2013 and May 2017. This trial is registered with the University Hospital Medical Information Network

Results

Of the 2588 patients included in the present study, 467 (18.0%) patients were categorized as low-risk (STS score < 4%), 1200 (46.4%) patients as intermediate-risk (4% ≤ STS score < 8%), and 921 (35.6%) as high-risk (8% ≤ STS score) (Figure 1). The baseline patient characteristics are summarized in Table 1. The median age of the included patients was 85 years, 31% of patients were male, and the median STS risk score was 6.6%. Statistically significant group differences in patient demographics

Discussion

The main findings of the study are as follows; 1) the present study showed that a considerable portion of TAVI procedures were performed in patients who were categorized as low- or intermediate-risk according to the STS score but who were considered to be high risk for SAVR; 2) procedural complication rates and in-hospital mortality were lower and comparable in low- and intermediate-risk patients, compared with high-risk patients; 3) the operative (30-day) mortality was quite lower than the

Author's Contributions

Kenichi Ishizu: Conceptualization, Methodology, Formal analysis, Writing - Original Draft. Shinichi Shirai: Writing - Review & Editing, Supervision. Akihiro Isotani: Data Curation. Masaomi Hayashi: Data Curation. Tomohiro Kawaguchi: Data Curation. Tomohiko Taniguhi: Data Curation. Kenji Ando: Supervision. Fumiaki Yashima: Writing - Review & Editing, Resources. Norio Tada: Review & Editing. Masahiro Yamawaki: Review & Editing. Toru Naganuma: Review & Editing. Futoshi Yamanaka: Review & Editing.

Acknowledgments

The authors thank the investigators and institutions that have participated in the OCEAN-TAVI registry.

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Cited by (16)

Impact of COVID-19 Surge Periods on Clinical Outcomes of Transcatheter Aortic Valve Implantation
2023, American Journal of Cardiology
Healthcare systems adopted various strategies to minimize the impact of the COVID-19 pandemic on clinical outcomes of patients with symptomatic severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI). We aimed to compare baseline characteristics and procedural and clinical outcomes of patients who underwent TAVI during COVID-19 surge periods with those of patients who underwent TAVI during the nonsurge and prepandemic periods. In the prospective Bern TAVI registry, the pandemic period was divided into surge and nonsurge periods on the basis of the mean number of occupied beds in the intensive care unit in each month and matched with 11 months immediately preceding the pandemic. A total of 1,069 patients underwent TAVI between April 1, 2019 and December 31, 2021. Patients who underwent TAVI during surge periods had a higher surgical risk (Society of Thoracic Surgeons predicted risk of mortality) than that of patients who underwent TAVI during nonsurge and prepandemic periods. Diagnosis-to-procedure time (in days) was longer for patients who underwent TAVI during the surge period than during the nonsurge and prepandemic periods (95.20 ± 121.07 vs 70.99 ± 72.25 and 60.46 ± 75.43, both p <0.001). At 30 days, all-cause mortality was higher in the surge than in the nonsurge group (4.9 vs 1.1%, hazard ratio 4.68, 95% confidence interval 1.55 to 14.10, p = 0.006), and in the surge than in the prepandemic group (4.9 vs 1.3%, hazard ratio 3.67, 95% confidence interval 1.34 to 10.11, p = 0.012). In conclusion, TAVI during COVID-19 surge periods was associated with higher Society of Thoracic Surgeons predicted risk of mortality score, delayed procedure scheduling, and increased 30-day mortality than that of TAVI during nonsurge and prepandemic periods.
Racial Difference in Mortality After Transcatheter Aortic Valve Replacement
2023, JACC: Asia
Race-Specific Impact of Conventional Surgical Risk Score on 1-Year Mortality After Transcatheter Aortic Valve Replacement
2023, JACC: Asia
Interracial differences in the distribution and prognostic value of conventional Society of Thoracic Surgeons (STS) score on long-term mortality after transcatheter aortic valve replacement (TAVR) are uncertain.
This study aims to compare the impact of STS scores on clinical outcomes at 1-year after TAVR between Asian and non-Asian populations.
We used the Trans-Pacific TAVR (TP-TAVR) registry, a multinational multicenter, observational registry involving patients undergoing TAVR at 2 major centers in the United States and 1 major center in Korea. Patients were classified into 3 groups (low, intermediate, and high-risk) according to the STS score and compared between STS risk groups and race. The primary outcome was all-cause mortality at 1-year.
Among 1,412 patients, 581 were Asian and 831 were non-Asian. The distribution of the STS risk score group was different between Asian and non-Asian groups (62.5% low-, 29.8% intermediate-, and 7.7% high-risk in Asian vs 40.6% low-, 39.1% intermediate-, and 20.3% high-risk in non-Asian). In the Asian population, the all-cause mortality at 1-year was substantially higher in the high-risk STS group than in the low- and intermediate-risk groups (3.6% low-risk, 8.7% intermediate-risk, and 24.4% high-risk; log-rank P < 0.001), which was primarily driven by noncardiac mortality. In the non-Asian group, there was a proportional increase in all-cause mortality at 1-year according to the STS risk category (5.3% low-risk, 12.6% intermediate-risk, and 17.8% high-risk; log-rank P < 0.001).
In this multiracial registry of patients with severe aortic stenosis who underwent TAVR, we identified a differential proportion and prognostic impact of STS score on 1-year mortality between Asian and non-Asian patients (TP-TAVR [Transpacific TAVR Registry]; NCT03826264)
Transcatheter aortic valve implantation versus surgical aortic valve replacement in chronic kidney disease: Meta-analysis of reconstructed time-to-event data
2023, Trends in Cardiovascular Medicine
Patients with advanced chronic kidney disease (CKD) are a challenging and understudied population. Specifically, the late outcomes following surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) in patients with CKD remains uncertain.
To compare overall mortality risk in patients with moderate-to-severe CKD following TAVI versus SAVR.
Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of studies published by August 2022.
Nine studies met our inclusion criteria. Patients who underwent TAVI had a higher 5-year mortality compared with patients undergoing SAVR in the overall population (HR 1.56, 95% CI 1.44–1.69, P < 0.001) and in populations with similar risk scores (HR 1.15, 95% CI 1.01–1.31, P = 0.035). The landmark analysis revealed a lower risk of 30-day mortality with TAVI (HR 0.62, 95% CI 0.41–0.94, P = 0.023), followed by similar risk until 7.5 months (HR 1, 95% CI 0.78–1.27, P = 0.978). In contrast, the landmark analysis beyond 7.5 months yielded a reversal of the HR in favor of SAVR (TAVI with HR 1.27, 95% CI 1.08–1.49 P = 0.003).
In patients with CKD, TAVI provides an initial survival benefit over SAVR. However, in the long run, a significant survival benefit of SAVR over TAVI was observed. Our findings highlight the need for randomized controlled trials to investigate outcomes in this special population.
Incomplete Functional Revascularization Is Associated With Adverse Clinical Outcomes After Transcatheter Aortic Valve Implantation
2022, Cardiovascular Revascularization Medicine
Citation Excerpt :
Cox proportional hazards models were fitted to estimate hazard ratios with 95% CI for treatment comparison. Hazard ratios (HR) were adjusted for clinical confounders defined a priori based on previous studies [22–25] and clinical significance, including age, sex, baseline glomerular filtration rate, STS score, and left ventricular ejection fraction. Moreover, variable that demonstrated a p-value <0.10 at the univariate Cox analysis were included in the final model.
Whether incomplete functional revascularization has an impact on the clinical outcome of patients treated with transcatheter aortic valve implantation (TAVI) is still unknown. We aim to assess the prognostic value of residual functional SYNTAX score (rFSS) in a cohort of patients undergoing TAVI.
One-hundred-twenty-four patients (229 lesions) with severe aortic stenosis and coronary artery disease (CAD) underwent fractional flow reserve (FFR)-guided revascularization. The primary endpoint of the study was the composite of cardiac death, myocardial infarction, and revascularization at the last available follow-up after TAVI. Median SYNTAX score (SS) and Functional SYNTAX score (FSS) at baseline were 7 (range 5–12) and 0 (range 0–7) respectively. After revascularization or deferral according to FFR, residual SS (rSS) and rFSS were 5 (range 0–8) and 0 (range 0–0) respectively. Angiographic incomplete revascularization (rSS > 0) was not associated with the primary endpoint (HR 1.2; 95% CI 0.4–3.9; p = 0.69), whereas functional incomplete revascularization (rFSS>0) was associated with worse event-free survival at follow up after adjusting for clinical confounders (HR 3.7; 95% CI 1.0–13.7; p = 0.04).
Incomplete functional revascularization is associated with adverse clinical outcomes after TAVI. Residual functional SYNTAX score may be regarded as a treatment goal for patients with CAD undergoing TAVI. Further studies are warranted to confirm our hypothesis.
Assessment of frailty prior to TAVI: Can it now be measured objectively?
2022, International Journal of Cardiology

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: The OCEAN-TAVI registry is supported by Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Medical, and Daiichi-Sankyo Company.

: Disclosures: Drs. Yamamoto, Tada, Naganuma, Shirai, Mizutani, Tabata, Ueno, and Watanabe are clinical proctors for Edwards Lifesciences and Medtronic. Drs. Takagi and Hayashida are clinical proctors of Edwards Lifesciences. The remaining authors have nothing to disclose.

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Long-Term Prognostic Value of the Society of Thoracic Surgery Risk Score in Patients Undergoing Transcatheter Aortic Valve Implantation (From the OCEAN-TAVI Registry)

Highlights

Section snippets

Methods

Results

Discussion

Author's Contributions

Acknowledgments

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