The Midterm Impact of Transcatheter Aortic Valve Replacement on Surgical Aortic Valve Replacement in Michigan Himanshu J. Patel, MD, Morley A. Herbert,

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The Midterm Impact of Transcatheter Aortic Valve Replacement on Surgical Aortic Valve Replacement in Michigan Himanshu J. Patel, MD, Morley A. Herbert, PhD, Gaetano Paone, MD, MHSA, John C. Heiser, MD, Francis L. Shannon, MD, Patricia F. Theurer, RN, BSN, Gail F. Bell, RN, MSN, Richard L. Prager, MD The Annals of Thoracic Surgery Volume 102, Issue 3, Pages 728-734 (September 2016) DOI: 10.1016/j.athoracsur.2016.02.106 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Impact of transcatheter aortic valve replacement (TAVR) dissemination on AVR volumes. (A) Total AVR volume in Michigan over 9.5 years. Hospitals with TAVR programs showed a dramatic increase in volume, especially when including TAVR. Those hospitals without TAVR programs also showed increase, but the overall impact was more modest, with TAVR typically reserved for high-risk patients (The Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] ≥8%). (B) Stable numbers in surgical AVR (SAVR) volume for high-risk patients for all hospitals in Michigan. When including TAVR, however, hospitals with transcatheter options showed dramatic increase in overall AVR volume in high-risk patients. Volume data are annualized for 2015 based on 6-month actual data in both A and B. (Hosp = hospital.) The Annals of Thoracic Surgery 2016 102, 728-734DOI: (10.1016/j.athoracsur.2016.02.106) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) for patients undergoing AVR over study period. There is slight decline in risk profiles assessed by the STS-PROM metric. As transcatheter aortic valve replacement (TAVR) programs were initiated, PROM continued to decrease in Michigan, particularly at TAVR hospitals, suggesting a shift in therapeutic paradigm for higher-risk patients. (Hosp = hospital; SAVR = surgical aortic valve replacement.) The Annals of Thoracic Surgery 2016 102, 728-734DOI: (10.1016/j.athoracsur.2016.02.106) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Observed to expected (O/E) ratios for aortic valve replacement (AVR) over study period. (A) O/E ratio for mortality is depicted for all patients undergoing AVR. This does not demonstrate trend in this ratio over study period. (B) Analysis is limited to patients considered at high risk for conventional AVR by The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM)(≥8%). (Hosp = hospital; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement.) The Annals of Thoracic Surgery 2016 102, 728-734DOI: (10.1016/j.athoracsur.2016.02.106) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions