Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Abstract

BackgroundAlthough transcatheter aortic valve replacement (TAVR) is the least invasive treatment for patients with symptomatic aortic stenosis, some patients hesitate to undergo the procedure. We investigated the clinical impact of treatment delay after patient refusal of TAVR.Methods and ResultsWe used the Japanese OCEAN (Optimized Catheter valvular intervention) regsitry data of 1542 patients who underwent TAVR. Refusal was defined as at least 1 refusal of TAVR at the time of informed consent. Patients were separated into 2 groups: refusal (28/1542, 1.8%) and non‐refusal (1514/1542, 98.2%). We compared the baseline characteristics, procedural outcomes, and mortality rates between the groups. Additionally, data on reasons for refusal and those leading to eventually undergoing TAVR were collected. Age, surgical risk scores, and frailty were higher in the refusal group than in the non‐refusal group (P<0.05 for all). Periprocedural complications did not differ between groups, whereas 30‐day and cumulative 1‐year mortality were significantly higher in the refusal group than in the non‐refusal group (7.1% versus 1.3%, P=0.008 and 28.8% versus 10.3%, P=0.010, respectively). Multivariate Cox regression analysis revealed that TAVR refusal was an independent predictor of increased midterm mortality (hazard ratio: 3.37; 95% confidence interval: 1.52–7.48; P=0.003). The most common reason for refusal was fear (13/28, 46.4%), and the most common reason for changing their mind was worsening heart failure (21/28, 75.0%). All patients in the refusal group decided to undergo TAVR within 20 months (median: 5.5 months).ConclusionsRefusing TAVR even once led to poorer prognosis; therefore, this fact should be clearly discussed when obtaining informed consent.

Restricted mean survival time of older adults with severe aortic stenosis referred for transcatheter aortic valve replacement

“…While frailty was commonly cited as a reason for choosing conservative medical management in our study and a previous study [16], frailty should not be equated with futility. It is important to note that one-half of TAVR patients manifest objective evidence of frailty at baseline, and that most still benefit from the procedure [17].…”

Calculated plasma volume status and outcomes in patients undergoing transcatheter aortic valve replacement

“…The better way to secure favourable prognoses is to perform TAVR before AS deteriorates. Recently, earlier interventions for severe AS have been increasingly advocated 23,24 . These studies suggest that the early treatment of severe AS results in more favourable outcomes, whereas delays in intervention only worsen the prognosis.…”

Current Key Issues in Transcatheter Aortic Valve Replacement Undergoing a Paradigm Shift

“…However, it should also be noted that refusal of TAVR, even only once, is associated with worse outcome. 16 Because patients with advanced frailty cannot undergo surgery because of their extremely high peri-operative risk, the only available treatment option for them is TAVR. Therefore, an assessment of frailty in patients undergoing TAVR should not serve as a barrier for the procedure but rather should be used for proper periprocedural management, such as nutritional support or rehabilitation.…”