Individual Operator Experience and Outcomes in Transcatheter Aortic Valve Replacement

The aim of this study was to assess the impact of individual operator experience on transfemoral transcatheter aortic valve replacement (TAVR) outcomes.

TAVR volume-outcome relationships have not been evaluated at the individual operator level.

New York Statewide Planning and Research Cooperative System data from 8,771 transfemoral TAVR procedures performed by 207 operators between 2012 and 2016 were analyzed. Operator volume was defined as the number of TAVR procedures performed during 1 year prior to the index procedure. Hierarchical and restrictive cubic spline regression models were used to evaluate the impact of individual operator experience on risk-adjusted in-hospital outcomes. The primary outcome was a composite of in-hospital mortality, stroke, and/or acute myocardial infarction. Secondary outcomes were the individual components of the primary outcome.

After adjusting for hospital and physician characteristics, patients undergoing TAVR performed by high-volume physicians (≥80/year) had a significantly lower risk for death, stroke, or acute myocardial infarction (odds ratio: 0.59; 95% confidence interval: 0.37 to 0.93) compared with those treated by low-volume physicians (<24/year). Being treated by operators who performed 200 procedures during the prior year was associated with significantly lower risks for post-procedural stroke (odds ratio: 0.41; 95% confidence interval: 0.17 to 0.97) and composite events (odds ratio: 0.45; 95% confidence interval: 0.26 to 0.78). This relationship was nonlinear, and a sensitivity analysis excluding the first 10, 20, and 30 procedures for each operator mitigated the effect of the initial learning curve.

Increased TAVR experience of operators is associated with improved risk-adjusted in-hospital outcomes. These results have potentially important implications for individual training and hospital programs in TAVR.