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Can J Cardiol. 2014 Oct;30(10):1162-9. doi: 10.1016/j.cjca.2014.03.009. Epub 2014 Mar 12.

Impact of wait times on the effectiveness of transcatheter aortic valve replacement in severe aortic valve disease: a discrete event simulation model.

Author information

  • 1Schulich Heart Centre, Division of Cardiology and Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada. Electronic address: harindra.wijeysundera@sunnybrook.ca.
  • 2Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada.
  • 3Schulich Heart Centre, Division of Cardiology and Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
  • 4Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
  • 5Schulich Heart Centre, Division of Cardiology and Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada.

Abstract

BACKGROUND:

There is increasing demand for transcatheter aortic valve replacement (TAVR) as the primary treatment option for patients with severe aortic stenosis who are high-risk surgical candidates or inoperable. We used mathematical simulation models to estimate the hypothetical effectiveness of TAVR with increasing wait times.

METHODS:

We applied discrete event modelling, using data from the Placement of Aortic Transcatheter Valves (PARTNER) trials. We compared TAVR with medical therapy in the inoperable cohort, and compared TAVR to conventional aortic valve surgery in the high-risk cohort. One-year mortality and wait-time deaths were calculated in different scenarios by varying TAVR wait times from 10 days to 180 days, while maintaining a constant wait time for surgery at a mean of 15.6 days.

RESULTS:

In the inoperable cohort, the 1-year mortality for medical therapy was 50%. When the TAVR wait time was 10 days, the TAVR wait-time mortality was 1.9% with a 1-year mortality of 31.5%. TAVR wait-time deaths increased to 28.9% with a 180-day wait, with a 1-year mortality of 41.4%. In the high-risk cohort, the wait-time deaths and 1-year mortality for the surgical patients were 2.5% and 27%, respectively. The TAVR wait-time deaths increased from 2.2% with a 10-day wait to 22.4% with a 180-day wait, and a corresponding increase in 1-year mortality from 24.5% to 32.6%. Mortality with TAVR exceeded surgery when TAVR wait times exceeded 60 days.

CONCLUSIONS:

Modest increases in TAVR wait times have a substantial effect on the effectiveness of TAVR in inoperable patients and high-risk surgical candidates.

PMID:
25047363
DOI:
10.1016/j.cjca.2014.03.009
[PubMed - indexed for MEDLINE]
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