Influence of Failure to Rescue on Mortality After Transcatheter Aortic Valve Replacement.
BACKGROUND: Mortality after transcatheter aortic valve replacement (TAVR) varies among centers. "Failure to rescue" (FTR) patients from post-TAVR complications may represent an unexplored opportunity for TAVR process improvement. METHODS: The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry was queried for patients undergoing transfemoral TAVR between 2011 and 2016. Hospital FTR rate was derived from the ratio of observed-to-expected procedural mortality. Multivariable logistic regression models assessed the association between FTR and hospital mortality. Adjusted FTR rates were compared across tertiles of hospital mortality. RESULTS: The analysis included 61,804 patients (429 sites). Post-TAVR mortality at low-, middle-, and high-mortality hospitals was 1.8%, 3.3%, and 5.6% (P < .01), respectively. Risk-adjusted complication rates differed only slightly between tertiles (22.2% vs 24.5% vs 27.0%, P < .001). However, adjusted FTR rates were significantly worse in high- and medium-mortality hospitals than in low-mortality centers (14.6% vs 9.5% vs 5.4%, P < .001). This was true for all investigated complications, including conversion to open surgery (high-mortality: odds ratio [OR], 9.04 [95% CI, 4.12-19.83], P < .001; medium-mortality: OR 2.99 [95% CI, 1.48-6.07], P < .003), stroke (high-mortality: OR, 3.15 [95% CI, 1.97-5.04], P < .001; medium-mortality: OR, 1.67 [95% CI, 1.05-2.67], P < .032), and cardiac arrest (high-mortality: OR, 3.54 [95% CI, 2.57-4.87], P < .001; medium-mortality: OR, 1.67 [95% CI, 1.24-2.24], P < .001). CONCLUSIONS: National TAVR mortality rates vary significantly across centers, despite comparable rates of postoperative complications. Patients at medium- and high-mortality centers face a disproportionately higher risk of death due to FTR. These findings highlight the need for a closer evaluation of post-TAVR care processes to address this disparity.
