Early noncardiac surgery with in one month after successful TAVI tied to better outcomes: JAMA

Switzerland: Noncardiac surgery can be performed early following successful transcatheter aortic valve implantation (TAVI), though suboptimal device performance, such as prosthesis-patient mismatch (PPM) and paravalvular regurgitation (PVR), is associated with an increased risk of adverse outcomes after noncardiac surgery, states an article published in JAMA Network Open.

Noncardiac surgery induces cardiac stress and hemodynamic alterations causing adverse cardiovascular events. The presence of severe aortic stenosis (AS) is associated with substantial increases in perioperative risk associated with noncardiac surgery. So, guidelines mandate aortic valve replacement (AVR) before surgery. Transcatheter aortic valve implantation (TAVI) offers a minimally invasive approach associated with a short reconvalescence period minimizing the delay between valve replacement and noncardiac surgery. Noncardiac surgery after transcatheter aortic valve implantation (TAVI) is a clinical challenge with concerns about safety and optimal management.

Okuno T, University of Bern, Switzerland, and his team performed an analysis to evaluate the perioperative risk of adverse events associated with noncardiac surgery after TAVI by the timing of surgery, type of surgery, and TAVI valve performance.

Researchers included 300 patients undergoing elective (160 patients) or urgent (140 patients) noncardiac surgery after TAVI in the analysis. The study was conducted using data from a prospective TAVI registry of patients at the tertiary care University Hospital. Timing, clinical urgency, and risk category of noncardiac surgery were assessed among patients who had undergone TAVI and subsequent noncardiac surgery. Procedures were categorized into low-risk (21 patients), intermediate-risk (190 patients), and high-risk (89 patients) surgery.

Main Outcomes were set as a composite of death, stroke, myocardial infarction, and major or life-threatening bleeding within 30 days after noncardiac surgery.

Key findings of the analysis,

• Composite endpoints occurred within 30 days of surgery among 58 patients.

• There were no significant differences in baseline demographics between patients with the 30-day composite endpoint and patients without this endpoint, including mean (SD) age and sex.

• Timing (ie, ≤30 days from TAVI to noncardiac surgery), urgency, and risk category of surgery were not associated with increased risk of the endpoint.

• Moderate or severe prosthesis-patient mismatch and moderate or severe paravalvular regurgitation were independently associated with increased risk of the endpoint.

The authors conclude that suboptimal device performance, such as PPM and PVR, was associated with an increased risk of adverse outcomes after noncardiac surgery, while timing, urgency, and risk category of noncardiac surgery were not associated with increased risk. The findings suggest that noncardiac surgery may be performed early after successful TAVI. Further studies are needed to explore the optimal treatment strategy for patients with AS requiring noncardiac surgery.

Reference:

Okuno T, Demirel C, Tomii D, et al. Risk and Timing of Noncardiac Surgery After Transcatheter Aortic Valve Implantation. JAMA Netw Open. 2022;5(7):e2220689.

doi:10.1001/jamanetworkopen.2022.20689