title: Phase of Care Mortality Analysis: A Unique Method for Comparing Mortality Differences Among Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Patients.
abstract: The objective of this study is based on the phase of care mortality analysis (POCMA), an effective tool to evaluate the root cause of in-hospital mortality in cardiac surgery patients. POCMA has not been used to compare operative mortalities among transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) populations, and may provide insight that could affect patient safety initiatives and improve outcomes in aortic valve surgery. We included patients who underwent TAVR or isolated SAVR between 2011 and March 31, 2015 and did not survive the index hospitalization. A multidisciplinary heart team made POCMA assignments as part of the weekly morbidity and mortality conference, pinpointing the phase of care and subcategory that directly caused or had the greatest effect on each mortality. During the study period, 240 patients underwent TAVR and 530 underwent SAVR. Unadjusted mortality rates were significantly higher in the TAVR group, 5.0% (n = 12) compared with SAVR, 1.9% (n = 10) (P = 0.016). TAVR deaths by phase of care are as follows: 0 for preoperative, 9 (72.8%) for intraoperative, 2 (18.2%) for postoperative intensive care unit, and 1 (9.1%) for postoperative floor. By comparison, 4 (40%) SAVR deaths had a root cause in the preoperative phase, 1 (10%) in the intraoperative phase, and 5 (50%) in the postoperative intensive care unit phase. POCMA is a novel method of categorizing in-hospital mortalities. Our single institution review revealed that patients who underwent TAVR more often expired because of intraoperative technical issues, whereas SAVR deaths were typically the result of patient selection or postoperative complications.
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Crawford
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: J Trent
authors.initials: JT
authors.lastname: Magruder
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Grimm
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Kaushik
authors.initials: K
authors.lastname: Mandal
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Joel
authors.initials: J
authors.lastname: Price
authors.affiliation: Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Jon
authors.initials: J
authors.lastname: Resar
authors.affiliation: Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Matthew
authors.initials: M
authors.lastname: Chacko
authors.affiliation: Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Rani K
authors.initials: RK
authors.lastname: Hasan
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Glenn
authors.initials: G
authors.lastname: Whitman
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: jconte@jhmi.edu.
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D015142:Baltimore; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D002423:Cause of Death; D003422:Critical Care; D016208:Databases, Factual; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D017052:Hospital Mortality; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D018579:Patient Selection; D011182:Postoperative Care; D011183:Postoperative Complications / Q000401:mortality; D011300:Preoperative Care; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome