Surgery After TAVR: Waiting a Month or More Not Really Better

People didn’t have to wait long after transcatheter aortic valve replacement (TAVR or TAVI) to safely undergo noncardiac surgery, though suboptimal device performance should give pause for another operation, a study suggested.

There was a 19.7% incidence of combined death, stroke, myocardial infarction, and major or life-threatening bleeding within 30 days after noncardiac surgery, according to an institutional registry counting all 300 patients undergoing such surgery after TAVR from 2013 to 2020.

Patient characteristics had no relationship with the 30-day outcome, nor did the surgery’s urgency, estimated risk, or its timing after TAVR, reported interventional cardiologist Thomas Pilgrim, MD, MSc, of University Hospital of Bern in Switzerland, and colleagues.

“This finding provides evidence in support of a strategy of prophylactic TAVI promptly followed by noncardiac surgery for patients with severe AS [aortic stenosis] requiring noncardiac surgery,” the authors wrote in JAMA Network Open.

Their registry revealed that noncardiac surgery followed TAVR within 30 days in 21% of cases, at days 31-180 in 25%, at 181-365 days in 23%, and more than a year after TAVR in 31%.

European and American guidelines currently recommend aortic valve replacement (AVR) prior to noncardiac surgery in people with severe aortic stenosis, given the condition’s association with perioperative complications during surgery.

“Aortic stenosis (if severe) is certainly a major risk factor for adverse events during/after non-cardiac surgery. By successfully treating the aortic stenosis, one would hypothesize that the valve-related risk of non-cardiac surgery would be mitigated, and these findings support that hypothesis,” said Ajay Kirtane, MD, SM, of NewYork-Presbyterian/Columbia University Irving Medical Center in New York City, in an email to MedPage Today.

Pilgrim’s team nevertheless cited two disadvantages to prophylactic AVR before noncardiac surgery.

“First, the accumulation of 2 successive major surgeries represents a major stress and is associated with prolonged reconvalescence. Second, prophylactic AVR is potentially associated with delayed noncardiac surgery owing to the time required for recovery from open-heart surgery,” the researchers wrote.

They found that only moderate or severe prosthesis-patient mismatch (adjusted HR 2.33, 95% CI 1.37-3.95) and moderate or severe paravalvular regurgitation (adjusted HR 3.61, 95% CI 1.25-10.41) were independent predictors of the composite endpoint at 30 days postsurgery.

“These results suggest that it is crucial to achieve optimal hemodynamic outcome when performing prophylactic TAVI before elective noncardiac surgery. If optimal device performance cannot be expected owing to challenging valve anatomy, surgical AVR may be prioritized as a prophylactic treatment,” Pilgrim and colleagues said.

The cohort study included 300 TAVR patients with an average age of 81.8 years, and 48.0% of whom were women.

Noncardiac surgeries counted both elective (n=160) and urgent procedures (n=140). They were also divided into low-risk (n=21), intermediate-risk (n=190), and high-risk (n=89) surgeries.

TAVR recipients most commonly underwent subsequent neurological or orthopedic major surgery (32.7%), followed by superficial (15.7%) and intraperitoneal surgery (13.7%).

Thirty-day outcomes after surgery included death in 9.6%, and bleeding in 11.3%.

“The rate of adverse events is still high, but this largely reflects the population being studied overall,” Kirtane commented.

Pilgrim’s team acknowledged that the registry lacked major variables such as anesthetic management, perioperative antithrombotic management, and perioperative complications. Study findings may also have limited generalizability to younger people or patients who were not offered or declined surgery.

Additionally, the observational nature of the study left room for residual confounding, the investigators said.