ABSTRACT
INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement and revolutionized the treatment strategy for aortic valve replacement. Little is known on the disparities among minorities, especially American Indians (AI), undergoing this procedure. We explore TAVR outcomes to identify disparities at our institution. METHODS: Retrospective chart review was completed on patients who underwent TAVR at a North Dakota community hospital between 2012 and 2021. There were 1133 non-AI and 20 AI patients identified (n = 1153). AI patients were identified by enrollment in nationally recognized tribes, Indian Health Service (IHS), or who self-identified as AI. Patient demographics, preoperative characteristics, procedural information, and outcomes were collected. United States 2020 census data was used for state-wide population racial percentages. Unpaired two tail t test assuming unequal variance and chi-squared tests were used to evaluate data and identify disparities between AI and non-AI. RESULTS: AI presented at an earlier age (71 vs. 79; p = .001) with higher rates of diabetes (60% vs. 35%; p = .018) and history of smoking (100% vs. 60%; p ≤ .001) than Caucasian/white (C/W). The Society of Thoracic Surgery (STS) risk scores (3.2% vs. 4.6%; p = .054) and aortic valve mean gradients were lower among AI (42.8 mmHg vs. 47.5 mmHg; p = .010). For those deceased, AI had significantly shorter lifespans post-TAVR compared to C/W (374 days vs. 755 days; p = .004). AI from North Dakota had fewer TAVR procedures performed than expected (4 actual vs. 32 expected; p < .001). CONCLUSIONS: AI undergoing TAVR presented earlier, with higher rates of diabetes and smoking, lower STS risk scores, and lesser aortic valve gradients than C/W. The number of TAVR procedures performed on AI from North Dakota was lower than anticipated despite a nearly 10-year period and the disparities experienced by AI who could have otherwise benefited from TAVR.
ABSTRACT
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) is common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
