Introduction: Transfemoral (TF) and transapical (TA) techniques for transcatheter aortic valve replacement have been validated in clinical trials. However, the impact of the choice of approach modality on resource utilization, mortality, and readmissions in clinical practice remains unclear.
Methods: Patients who underwent transcatheter aortic valve replacement (ICD 9: 35.05, 35.06) in the 2011-2014 National Readmission Database (NRD) and the Nationwide Inpatient Sample (NIS) Databases for whom readmission data was available were analyzed. The NRD and NIS are all-payer inpatient databases maintained by the Healthcare Cost and Utilization Project (HCUP) that estimate more than 35 million annual U.S. hospitalizations. Mortality, readmission, and GDP-adjusted cost were evaluated using hierarchical linear models adjusting for socioeconomic, demographic and comorbidity measured by Elixhauser Index.
Results: 38,929 patients underwent TAVR during the study period, 8,643 (22%) received a TA approach while 30,285 (78%) received a TF approach. TA patients were more likely female (52% vs 46%, P<0.001), more likely from ZIP codes with median income below the national median (48% vs 44%, P<0.001), and had higher Elixhauser Index (CI: 6.5 vs 6.1, P<0.001). The TA approach was associated with higher adjusted mortality at discharge (6.7% vs 3.8% OR=1.7, P<0.001), higher cost ($65,591 vs $56,595, β=0.14 , P<0.001), and longer stays (11 vs 8.3 days, IRR=1.28, P<0.001). All-cause readmission was significantly higher in TA patients within 30 days (20% vs 16%, OR=1.27, P<0.001).
Conclusion: In this study of 38,929 U.S. patients who underwent TAVR from 2011-2014, after adjustment for demographics, comorbidities, and hospital level variation, the TA approach was 14% more expensive, had 27% higher odds of readmission within 30 days, 28% longer length of stay, and 70% greater odds of mortality compared to TF approach. Our findings support the preference for the TF approach where technically feasible.