Psychosocial Risk Factors in Aortic Valve Replacement Outcomes in Adult Patients

Significantly worse 30-day outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are associated with psychosocial risk factors (PSRFs), according to study findings published in the Journal of the American College of Cardiology: Cardiovascular Interventions.

Investigators sought to assess the influence of psychosocial risk factors on short-term outcomes following SAVR and TAVR in adult patients. Primary endpoints included readmission, 30-day mortality, and composite morbidity (myocardial infarction, new atrial fibrillation, acute kidney injury, bleeding complications, pacemaker implantation, pulmonary embolus, or stroke).

They conducted a nationally representative analysis in the United States using the Nationwide Readmissions Database to identify all adult patients in the database at least 18 years of age who received SAVR (n=74,763) and TAVR (n=87,142) from 2016 to 2018. Patients were stratified as having no psychosocial risk factors or at least 1 psychosocial risk factor. Psychosocial risk factors were defined as low socioeconomic status (SAVR, 22.7%; TAVR, 19.9%), uninsured status (SAVR, 1.7%; TAVR, 0.3%), psychiatric disease (SAVR, 18.1%; TAVR. 13.2%), substance use (SAVR, 14.6%; TAVR, 5.5%), or limited cognitive comprehension (SAVR, 1.0%; TAVR, 4.3%).

The investigators noted that 45.1% of patients in the SAVR group had at least 1 psychosocial risk factor, and 36.4% of patients in the TAVR group had at least 1 psychosocial risk factor. Patients with at least 1 psychosocial risk factor in the SAVR group vs patients with no psychosocial risk factors were more likely to be women (35.0% vs 28.0%; P <.001) and were significantly younger (64.3 vs 67.5 years of age; P <.001). Between these groups, overall comorbidity burden was similar. Patients with at least 1 psychosocial risk factor in the TAVR group showed similar demographics, tending to be younger and women, and they also had similar comorbidity burden between groups.

The investigators found that patients with at least 1 psychosocial risk factor and who received SAVR had significantly higher readmissions vs patients with no psychosocial risk factors (13.1% vs 11.3%; P <.001) and significantly higher 30-day mortality vs patients with no psychosocial risk factors (4.2% vs 3.7%; P =.048). They found no difference in composite morbidity in this study group.

Among patients with at least 1 psychosocial risk factor and who received TAVR, investigators observed a significantly higher 30-day readmission vs patients with no psychosocial risk factors (11.7% vs 10.7%; P =.012). They found no difference in composite morbidity or 30-day mortality in this study group.

Risk-adjusted analysis revealed that psychosocial risk factors were a significant predictor of higher 30-day readmissions in patients who received SAVR (adjusted odds ratio, 1.10; 95% CI, 1.02-1.19).

Study limitations include database billing code inaccuracies and lack of granular clinical or operative details. There are also unaccounted for out-of-hospital events and readmissions out-of-state or across calendar years.

“Together these findings suggest that PSRFs [psychosocial risk factors] are important nontraditional risk factors that contribute to socioeconomic disparities and are important for clinicians to recognize when identifying patients who are at risk for worse postoperative outcomes,” the study authors wrote. “Furthermore, PSRFs should be utilized by the structural heart team as another tool to help guide the decision to proceed with SAVR vs TAVR, as less invasive procedures like TAVR may be beneficial in patients with PSRFs due to its faster and less intensive recovery period, although further research to validate these findings is needed.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.