Canadian Journal of Cardiology
Clinical Research|Articles in Press

Regional Differences in Outcomes for Patients Undergoing Transcatheter Aortic Valve Replacement in New York State and Ontario

Published:February 01, 2023DOI:



      Transcatheter aortic valve replacement (TAVR) has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR among jurisdictions. It is unknown if such variation is associated with differences in postprocedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high vs low access of care to TAVR translate to differences in postprocedural outcomes.


      In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1, 2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all-cause readmissions. Using indirect standardization, we calculated the observed vs expected outcomes for New York patients, had they been treated in Ontario.


      Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5% of New York patients. With adjustment, this translated to an observed-expected ratio of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients.


      Having greater access to TAVR may be associated with improved outcomes, potentially because of intervention earlier in the trajectory of the disease.



      L’implantation transcathéter de la valve aortique (ITVA) est maintenant la norme de soins chez la majorité des patients atteints de sténose aortique grave, mais l’accès à l’ITVA varie considérablement d’une région à l’autre. Or, on ne sait pas si cette variation est associée à des différences quant aux résultats après l’intervention. Notre objectif était donc de déterminer si les résultats après une ITVA varient selon que l'accès est élevé ou faible dans une région donnée.


      Dans cette étude de cohorte observationnelle et rétrospective, nous avons répertorié tous les résidents de l’Ontario et de l’État de New York âgés de plus de 18 ans qui avaient subi une ITVA entre le 1er janvier 2012 et le 31 décembre 2018. Les principaux résultats après une ITVA étaient la mortalité hospitalière et les réadmissions toutes causes confondues à 30 jours. En utilisant la standardisation indirecte, nous avons calculé les résultats observés par rapport aux résultats attendus pour les patients de New York, s’ils avaient été traités en Ontario.


      La cohorte était composée de 16 814 patients ayant subi une ITVA dans 36 hôpitaux de l’État de New York et de 5007 patients ayant subi une ITVA dans 11 hôpitaux de l’Ontario. Dans cette province, les taux d’accès à l’ITVA sont passés d’environ 18,2 par million d’habitants en 2012 à 87,4 par million d’habitants en 2018, tandis que pour l’État de New York, les taux ont augmenté de 31,9 à 220,4 par million d’habitants. En ce qui concerne la mortalité à 30 jours, 3,1 % des patients ayant subi une ITVA en Ontario sont décédés à l’hôpital contre 2,5 % des patients de l’État de New York. Après ajustement, le rapport des résultats observés/attendus était de 0,70 (intervalle de confiance à 95 % [IC] : 0,54-0,92) pour les patients de New York.


      Un meilleur accès à l’ITVA peut être associé à de meilleurs résultats, potentiellement en raison d’une intervention plus précoce dans la trajectoire de la maladie.

      Graphical abstract

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