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Preoperative Pulmonary Function Tests as Predictors of Postoperative Morbidity and Mortality: A Multi-Institutional Analysis of 915 TAVR Patients
Amanda L. Maas1, Michael Mack2, Gorav Ailawadi3, Rakesh M. Suri4, Wilson Szeto5, Patrick Kilgo1, Todd Dewey2, Jacob R. Gillen3, John A. Kern3, Nimesh Desai5, Vuyisile T. Nkomo4, Rohan Menon5, Rebeca Kim2,
Vinod H. Thourani1.
1Emory University, Atlanta, GA, USA, 2CRSTI, Dallas, TX, USA, 3University of Virginia, Charlottesville, VA, USA, 4Mayo Clinic, Rochester, MN, USA, 5University of Pennsylvania, Philadelphia, PA, USA.

Objective: Pulmonary dysfunction is a known risk factor for complications following conventional surgical AVR, but has not been well defined in the TAVR population. Currently, preoperative COPD severity is classified as mild, moderate, or severe using FEV1%. This study sought to assess if preoperative PFTs or TAVR approach were predictive of pulmonary complications and short-term mortality. Methods: From 5/2008 - 3/2013, 915 patients with preoperative PFTs underwent TAVR for severe AS at 5 US academic institutions. Patients were stratified by COPD severity based on FEV1% (no COPD: >75%, mild: 60-75%, moderate: 50-59%, severe: <50%). Pulmonary morbidity and 30-day mortality were analyzed in relation to PFT metrics (FEV1%, FEV1/FVC% and DLCO%) and TAVR approach (transfemoral [TF], transapical [TA], or OTHER [transaortic, transaxillary, and trancarotid]). Results: For all patients, the mean age was 82±8 years and mean STS PROM was 10.5%±6.0%. Based on FEV1%, 44.1% (394/893) had no COPD, 22.6% (202/893) had mild, 14.2% (127/893) had moderate, and 19.1% (170/893) had severe COPD. TAVR approach was 54.0% (463/858) TF, 39.4% (338/858) TA, and 6.6% (57/858) OTHER. There were no differences in pulmonary outcomes across COPD classes or when FEV1/FVC% and DLCO% were dichotomized to 50%. The only significant difference in 30-day mortality using these metrics was seen in the dichotomized DLCO% comparison. When stratified by approach, incidence of pneumonia, prolonged ventilation, and ventilation time were highest in the TA group. 30-day mortality was lowest in the TF group when compared to the TA and OTHER cohort (Table 1). Conclusions: Preoperative COPD is common among patients undergoing TAVR, however, the current classification utilizing FEV1% was not useful in predicting 30-day mortality or pulmonary morbidity. Similarly, FEV1/FVC% was not predictive of these outcomes. Low DLCO% was predictive of higher 30-day mortality rate, but not of postoperative pulmonary complications. Our findings suggest that COPD should not prohibit patients from undergoing TAVR and highlights that patients undergoing TA TAVR have the highest risk of pulmonary morbidity.

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