Insight into the Optimal Timing of Percutaneous Coronary Intervention and Transcatheter Aortic Valve Replacement

Abstract

Background

Patients being considered for transcatheter aortic valve replacement (TAVR) are frequently diagnosed with coronary artery disease. In patients requiring revascularization, there is a paucity of data informing when to perform percutaneous coronary artery intervention (PCI).

Objectives

We evaluated the impact of PCI timing on clinical outcomes and readmissions after TAVR.

Methods

From the National Readmissions Database 2016 to 2019, we stratified the duration between PCI and TAVR into 3 groups: same-day PCI and TAVR, TAVR ≤30 days after PCI, and TAVR >30 days after PCI. We then compared primary and secondary outcomes among them.

Results

A total of 5,207 patients were included, 1,413 (27.1%) of whom underwent PCI and TAVR on the same day, while 2,161 (41.5%) underwent TAVR ≤30 days after PCI and 1,632 (31.3%) underwent TAVR >30 days after PCI. There was no significant difference for in-hospital mortality among the groups (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.16-1.48, p=0.203 for same-day versus ≤30 days; aOR 2.07, 95% CI 0.68-6.30, p=0.199 for same-day versus >30 days). Patients who underwent TAVR ≤30 days after PCI had higher odds of acute kidney injury (aOR 1.49, 95% CI 1.05-2.10, p=0.024), non-home discharge (aOR 1.53, 95% CI 1.20-1.96, p=0.001), and 90-day readmission (aOR 1.35, 95% CI 1.04-1.76, p=0.026) compared with those who underwent same-day PCI and TAVR.

Conclusions

Concomitant PCI and TAVR was associated with lower rates of 90-day readmissions and acute kidney injury compared with TAVR shortly after PCI (≤30 days) and should be considered in select patients.

Graphical Abstract

The graphical abstract illustrates the main findings of this study, which compared PCI ≤30 days before TAVR and PCI >30 days before TAVR with same-day PCI and TAVR. Abbreviations: PCI, percutaneous coronary intervention; TAVR, transcatheter aortic valve replacement

Introduction

Transcatheter aortic valve replacement (TAVR) offers a non-surgical option for treatment of aortic stenosis^1-5. Coronary artery disease (CAD) is a frequently diagnosed comorbid condition in patients with severe aortic stenosis. In a recent review of major TAVR trials, the prevalence of CAD ranged from 15% to 80%, with multivessel disease identified in approximately 50% of these patients⁶. Therefore, both the American and European practice guidelines recommend systematic evaluation of CAD in patients being evaluated for aortic valve replacement^{7, 8}. In cases felt to be appropriate for percutaneous coronary intervention (PCI), there is no clear definition as to when operators should intervene, namely before TAVR, during TAVR, or after TAVR. There are many arguments favoring different strategies, citing technical concerns related to post-TAVR PCI^{9, 10} and findings from prior observational data. Some studies in the literature have suggested differing rates of renal failure related to procedural timing^{11, 12}, as well as bleeding¹³, but no studies have shown differences in mortality. To our knowledge, there is no randomized data on timing of PCI and TAVR to date, although one trial is currently ongoing (TAVI PCI, NCT04310046).

Given rising healthcare expenditure in the United States¹⁴, payers are searching for alternative strategies to reduce costs and share savings. A prime example is in the bundled payment models, in which the payer offers a single payment for all expected costs involved in a procedure for a certain period of time (most commonly 90 days). In such a model, the incentive is to identify ways to reduce extraneous payments, one of which would be re-hospitalizations. As many as a quarter of TAVR patients are re-hospitalized within the first 90 days of the procedure, with associated cost increases¹⁵. Thus, approaches to minimize avoidable rehospitalizations, especially within the first 90 days of TAVR, are of prime importance to clinicians, patients, and healthcare systems.

In this analysis of the Nationwide Readmissions Database (NRD), our objectives were to identify whether there are any differences in clinical outcomes for patients undergoing TAVR ≤30 days after PCI and TAVR >30 days after PCI, then identify whether there are differences in rates of rehospitalization within the first 90 days after the TAVR procedure among patients with different revascularization timing strategies.

Methods

Study Design and Data Set

We retrospectively analyzed all adults 18 years and older who underwent PCI then TAVR from the 2016 to 2019 NRD. In brief, the NRD is an all-payer database that samples approximately 60.4% of all hospitalizations from 27 to 30 States (27 in 2016, 28 in 2017-2018, and 30 in 2019) in the United States¹⁶. Developed for the Healthcare Cost and Utilization Project (HCUP), the NRD provides verified patient linkage numbers from the State Inpatient Databases that can be used to track each patient’s admissions within the State in the same year while maintaining strict anonymity. The NRD provides a large sample size, allowing the nationally representative study of disorders and procedures that would be otherwise difficult to analyze using conventional registries and databases.

Study Groups and Outcomes

Patients who underwent PCI then TAVR, either subsequently or simultaneously, were identified using International Classification of Disease, Tenth Revision, Procedure Coding System (ICD-10-PCS) codes. The NRD provides a variable called “PRDAY” which represents the day from the admission until the specific procedure. Using this variable, we determined the duration between PCI and TAVR and excluded all the TAVRs that were performed before PCI. Patients who underwent TAVR following or on the same day as PCI were stratified into the following groups: (1) those who underwent PCI and TAVR on the same day; (2) those who underwent TAVR ≤30 days after PCI, and (3) those who underwent TAVR >30 days after PCI (Figure 1). Patients without a diagnosis of chronic ischemic heart disease during PCI were excluded. Patients who underwent transapical TAVR were excluded as this approach was no longer deemed the standard of care. Patients with missing in-hospital outcomes or demographic information were excluded. To improve the homogeneity of our sample, patients with acute coronary syndrome, cardiogenic shock, temporary mechanical support, or cardiac surgery during admission for either PCI or TAVR were excluded, similar to a previous study¹⁷. Patients who encountered mechanical complication during admission for TAVR were also excluded. Because the NRD does not track hospitalizations across years, TAVRs occurring in October, November, and December were excluded to guarantee 90-day follow-up in the same calendar year. Baseline characteristics and procedural information were defined using ICD-10-PCS and International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. All the codes used in our study can be found in Table S1. Hospital characteristics, primary payer, median income, and admission type (elective versus non-elective) were defined in accordance with the NRD data dictionary¹⁸. Primary outcome was set as in-hospital mortality. Secondary outcomes included 90-day readmissions after TAVR, perioperative complications (atrioventricular block, pacemaker implantation, ischemic stroke, gastrointestinal hemorrhage, need for blood transfusion, acute kidney injury [AKI]), non-home discharge, and total hospital cost inclusive of both PCI and TAVR admissions.

Figure 1. Flow chart of this study.

The flow chart illustrates the inclusion and exclusion criteria of this study through which the analyzed cohort was selected.

Abbreviations: NRD, National Readmissions Database; PCI, percutaneous coronary intervention; TAVR, transcatheter aortic valve replacement

As a supplementary analysis, we included patients who underwent revascularization with PCI after admission for TAVR using identical inclusion criteria and likewise excluded patients who underwent PCI for acute coronary syndrome or cardiogenic shock, underwent mechanical circulatory support or cardiac surgery, or experienced mechanical complications. We compared in-hospital outcomes during admission for TAVR in patients who underwent PCI before TAVR (pre-TAVR group) and those who underwent PCI after TAVR (post-TAVR group) versus those who underwent same-day PCI and TAVR (same-day group). In-hospital mortality was excluded from the outcomes as the post-TAVR group, by definition, survived the TAVR and underwent PCI in a subsequent admission.

Statistical Methods

Discharge weights (“DISCWT”)¹⁸ were applied in all comparisons and analyses to generate nationally representative findings. Categorical and continuous variables in baseline and procedural characteristics were summarized as percentages and means and compared using chi-squared tests and analysis of variance (ANOVA), respectively. Multivariable logistic or linear regressions adjusted for demographics, comorbidities, hospital characteristics, primary payer, median income, admission type, and procedural characteristics was employed to compare each of the groups with same-day PCI and TAVR serving as the reference. All the covariates were adjusted as it was determined that they can be clinically important confounders. In addition, we examined non-linear associations between duration between PCI and TAVR and the risk of prespecified outcomes using cubic spline figures. Prespecified comparisons among (1) same-day PCI and TAVR versus (2) TAVR ≤30 days from PCI and (3) TAVR >30 days from PCI were examined. Identical methods were used in the supplementary analysis comparing pre-TAVR group and post-TAVR group with same-day group. Data curation, comparison of general characteristics, and regression analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, NC). Illustration of spline graphs was performed using ggplot package in R version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria).

Results

A total of 5,206 patients who underwent TAVR on the same day as or after PCI were included in our analysis. After stratification, 1,413 (27.1%) patients had undergone PCI and TAVR on the same day, while 2,161 (41.5%) patients underwent TAVR ≤30 days after PCI and 1,632 (31.3%) patients underwent TAVR >30 days after PCI (Figure 1). The distribution of PCI and TAVR procedures across different durations is illustrated in Figure 2. The baseline characteristics of patients, including sex, age, and comorbidities were widely heterogenous among the groups, as demonstrated by the greater proportion of patients who underwent PCI and TAVR on the same day who had lower prevalence of diabetes, atrial fibrillation, pulmonary hypertension, and chronic kidney disease, and higher median income. Intravascular imaging and mechanical thrombectomy were less utilized in this group while undergoing PCI (Table 1).

Figure 2. Distribution of PCI and TAVR procedures across different durations between PCI and TAVR.

The bar graph illustrates the number of patients who underwent both PCI and TAVR stratified into different durations between PCI and TAVR.

Abbreviations: PCI, percutaneous coronary intervention; TAVR, transcatheter aortic valve replacement

Table 1.

General characteristics of patients who underwent both PCI and TAVR

	Same Day	≤30 Days	>30 Days	P-value
N (sample)	904	1,221	916
N (weighted)	1,413	2,161	1,632
Male, %	53.0	58.4	57.8	0.032
Age, mean ± SD	80.5 ± 8.1	81.1 ± 7.8	81.2 ± 7.4	0.105
Comorbidities, %
Smoking	37.2	41.4	40.4	0.128
Hypertension	88.8	83.2	77.3	<0.001
Diabetes mellitus	37.0	42.3	41.6	0.034
Hyperlipidemia	73.5	75.4	73.1	0.415
Obesity	19.0	18.1	17.9	0.800
Heart failure	69.4	68.8	59.6	<0.001
Atrial fibrillation	33.5	40.1	40.2	0.003
Peripheral artery disease	17.2	18.5	15.4	0.167
Previous stroke	14.8	16.1	14.1	0.437
Previous PCI	2.4	2.1	2.0	0.757
Previous CABG	9.1	11.0	12.7	0.049
Previous pacemaker	10.2	9.4	10.5	0.697
Chronic pulmonary disease	24.1	25.8	26.6	0.452
Pulmonary hypertension	12.3	25.4	23.9	<0.001
Chronic kidney disease	32.3	40.5	39.3	<0.001
End-stage renal disease	4.1	5.7	5.2	0.230
Liver cirrhosis	1.7	2.3	2.0	0.585
History of malignancy	20.0	19.6	18.9	0.827
Deficiency anemia	4.0	7.0	7.1	0.005
Malnutrition	2.9	4.8	1.8	<0.001
Major depression	0.1	0.3	0.4	0.426
Dementia	5.8	6.6	5.0	0.325
Hospital characteristics
Location (%)				<0.001
Large metropolitan	72.0	70.4	64.7
Small metropolitan	28.0	29.3	33.8
Micropolitan	0.0	0.3	1.5
Bed size (%)				<0.001
Small	2.1	4.3	7.1
Medium	19.5	23.2	22.3
Large	78.4	72.6	70.6
Teaching status (%)				<0.001
Non-teaching	15.9	12.3	16.5
Teaching	84.1	87.7	83.5
Primary Payer (%)				0.074
Medicare	89.7	92.3	93.1
Medicaid	0.7	1.1	1.1
Private insurance	7.5	5.4	4.8
Self-pay	0.6	0.2	0.1
Others	1.6	1.1	0.9
Median income (%)				<0.001
Quartile 1	14.4	21.4	20.8
Quartile 2	20.9	23.5	25.0
Quartile 3	28.9	26.5	24.9
Quartile 4	35.8	28.6	29.3
Elective admission (%)
PCI	74.2	39.7	40.5	<0.001
TAVR	74.2	60.3	86.5	<0.001

Abbreviations: CABG = coronary artery bypass graft; PCI = percutaneous coronary intervention; SD = standard deviation

Compared with patients who underwent PCI and TAVR on the same day (1.2%), those who underwent TAVR ≤30 days after PCI (1.0%, adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.16-1.48, p=0.203) and those who underwent TAVR >30 days after PCI (1.4%, aOR 2.07, 95% CI 0.68-6.30, p=0.199) had no difference in the odds of in-hospital mortality (Table 2). However, patients who underwent TAVR ≤30 days after PCI had higher odds of acute kidney injury (aOR 1.49, 95% CI 1.05-2.10, p=0.024), non-home discharge (aOR 1.53, 95% CI 1.20-1.96, p=0.001), and 90-day readmission (aOR 1.35, 95% CI 1.04-1.76, p=0.026) compared to those who underwent same-day PCI and TAVR. Patients who underwent TAVR >30 days after PCI also had higher odds of non-home discharge (aOR 1.37, 95% CI 1.04-1.82, p=0.027), but no differences were seen in the odds of acute kidney injury and 90-day readmission. Both TAVR ≤30 days and >30 days after PCI groups had higher total hospital costs across both PCI and TAVR admissions compared with same-day PCI and TAVR group (Table 2). There were no differences in the odds of atrioventricular block, pacemaker placement, ischemic stroke, gastrointestinal hemorrhage, and need for blood transfusion among the three groups (Figure 3).

Table 2.

Comparison of in-hospital outcomes among different intervals between PCI and TAVR

Outcome	Same Daya	≤30 Days	aOR (95% CI)	P-value	>30 Days	aOR (95% CI)	P-value
In-hospital mortality, %	1.2	1.0	0.49 (0.16-1.48)	0.203	1.4	2.07 (0.68-6.30)	0.199
Atrioventricular block, %	16.0	17.5	1.06 (0.80-1.41)	0.668	15.4	1.34 (0.94-1.92)	0.104
Pacemaker placement, %	11.1	11.3	0.91 (0.65-1.28)	0.598	9.5	0.91 (0.61-1.37)	0.657
Ischemic stroke, %	6.9	8.3	1.16 (0.78-1.72)	0.459	7.8	1.03 (0.67-1.58)	0.900
Gastrointestinal hemorrhage, %	1.9	1.6	0.55 (0.28-1.08)	0.083	1.5	1.04 (0.46-2.33)	0.934
Need for blood transfusion, %	7.9	10.6	1.05 (0.73-1.51)	0.798	9.6	1.33 (0.84-2.09)	0.223
Acute kidney injury, %	10.0	17.1	1.49 (1.05-2.10)	0.024	9.5	1.12 (0.74-1.68)	0.600
Non-home discharge, %	35.8	50.1	1.53 (1.20-1.96)	0.001	41.5	1.37 (1.04-1.82)	0.027
90-day readmission, %	18.2	27.3	1.35 (1.04-1.76)	0.026	24.8	1.38 (0.99-1.91)	0.058
Total hospital cost, $	64,224	108,812	38,999 (34,574-43,424)b	<0.001	75,951	8,242 (5,380-11,103)b	<0.001

^aSame-day PCI and TAVR serve as the reference with which other groups are compared

^bAdjusted mean difference

Abbreviations: aOR = adjusted odds ratio; CI = confidence interval

Figure 3. Outcomes in TAVR ≤30 days and >30 days after PCI.

The plots show the adjusted odds of TAVR ≤30 days after PCI and TAVR >30 days after PCI for each of the outcomes with same-day PCI and TAVR serving as the reference. The vertical lines inside the boxes represent the adjusted odds ratio whereas the horizontal lines show the respective 95% confidence intervals. The size of the blue box is inversely proportional to the length of the confidence interval. Adjusted odds ratio above 1 favors same-day PCI and TAVR, and vice versa.

Abbreviations: aOR, adjusted odds ratio; PCI, percutaneous coronary intervention; TAVR, transcatheter aortic valve replacement

A supplementary analysis was conducted to compare patients who underwent PCI after TAVR (Table S3-S4). We identified 172 patients (3.2%) in the post-TAVR group compared with the 1,413 (26.3%) in the same-day group and 3,793 (70.5%) in the pre-TAVR group. No differences in the odds of atrioventricular block, pacemaker placement, ischemic stroke, gastrointestinal hemorrhage, need for blood transfusion, and acute kidney injury were seen among the pre-TAVR and post-TAVR groups versus the same-day group (Table S5). However, both pre-TAVR and post-TAVR groups had higher total hospital costs across both PCI and TAVR admissions compared with the same-day group.

The cubic spline graphs of the adjusted odds of prespecified outcomes with same-day PCI and TAVR as reference are shown in Figure 4. The p-value for non-linearity was non-significant for all outcomes apart from in-hospital mortality. However, the adjusted odds of acute kidney injury, non-home discharge, and 90-day readmission were initially increased, showing an inverted “U” shape, which dissipated as the time between PCI and TAVR increased.

Figure 4. Spline graphs for each outcome of interest.

The cubic spline graphs illustrate the adjusted odds of each duration between PCI and TAVR when compared with same-day PCI and TAVR. The dark blue lines represent the adjusted odds ratio, and the blue shades represent 95% confidence intervals.

Abbreviations: PCI, percutaneous coronary intervention; TAVR, transcatheter aortic valve replacement

Discussion

In this large analysis of the NRD, there were no significant differences in the rates of in-hospital mortality for patients undergoing PCI in the same day compared with those undergoing PCI ≤30 days or >30 days prior to TAVR. However, the rate of 90-day readmissions was higher in patients undergoing TAVR ≤30 days after PCI compared to those having the procedure done in the same day. The rate of acute kidney injury was also significantly higher in patients undergoing PCI ≤30 days of TAVR compared with those undergoing PCI on the same day. Finally, supplementary analysis showed no difference in any of the outcomes between pre-TAVR or post-TAVR PCI compared with same-day PCI and TAVR.

CAD is frequent in the TAVR population⁶, but the choice of treatment, or necessity of invasive treatment^{19, 20} is not always clear. As is widely known, patients with complex CAD or disease requiring revascularization were excluded from major TAVR trials^1-5. Limited observational data, however, show a rate of major adverse cardiac and cerebrovascular events of 52.1% at 5 years in patients with complex CAD undergoing TAVR and PCI, versus 38.2% in those undergoing surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG), with curves crossing at around one year²¹. These findings were confirmed by a recent meta-analysis with over 30,000 patients²². In patients with non-complex CAD, however, data from the SURTAVI and PARTNER III trials suggest equivalent outcomes between PCI and CABG in the aortic stenosis population^{1, 11}.

Among the many questions involving “PCI-appropriate” TAVR patients, one of the most relevant pertains to timing of the procedure. Operators may choose to intervene before, concurrently to, or, more rarely, after TAVR. The benefits of intervening prior (or immediately prior) to TAVR are based on the difficulty of evaluating the contribution of coronary artery disease in the setting of severe aortic stenosis to symptomatology, a potential (but not certain^{23, 24}) prognostic advantage in patients with “complete” revascularization²⁵, and the technical challenges involved in performing PCI in a patient with a transcatheter heart valve^{9, 10}. However, the existing data on whether to intervene in a staged or concurrent fashion is more nebulous.

Our analysis adds to the body of literature showing no difference in mortality for patients undergoing same day versus TAVR staged following PCI (either beyond 30 days or within 30 days). A small meta-analysis including 209 patients undergoing concomitant or staged procedures did not find any significant difference in 30-day mortality²⁶. A single-center report from an experienced center with 258 patients showed no difference in major adverse cardiac and cerebrovascular events at two years between patients undergoing pre-procedural, concomitant, or post-procedural TAVR²⁷. An older analysis of the NRD also did not show significant differences in mortality among revascularization timing strategies¹⁷.

However, we have been able to identify important differences that may support the selection of one strategy over the other. In the current analysis, patients undergoing concomitant PCI had significantly lower rates of acute kidney injury compared to those who underwent TAVR staged within 30 days of PCI. This represents a confirmation of the findings seen in the SURTAVI trial, which also showed significantly lower rates of acute kidney injury in patients undergoing concomitant PCI and TAVR (2% vs. 11.8%)¹¹. While this may appear incongruent at first, one of the possible explanations would be that operators are more cautious with contrast use when performing a concomitant procedure. However, it may also be that patients who underwent simultaneous procedures had better renal functions. In the SURTAVI trial, patients undergoing concomitant procedures received almost 100 mL less contrast dye on average when compared to their staged counterparts (308.1 mL vs. 217.2 mL, respectively; p < 0.01)¹¹. A meta-analysis from 2017 showed the opposite finding, with higher rates of renal failure in patients undergoing concomitant procedures¹². However, contrast loads were also higher in patients subjected to concomitant procedures¹². Therefore, operators may prioritize a contrast-sparing concomitant strategy, especially in patients with chronic kidney disease, when performing PCI and TAVR.

An earlier report showed higher rates of minor bleeding and vascular injury in patients undergoing PCI within 30 days of TAVR¹³, a finding thought to be related to the use of anti-platelet therapy. In our analysis, there was no significant difference in bleeding among staged and concomitant procedures. While the impact of anti-platelet on bleeding may still be relevant, one must note that the analysis from 2015 showing a difference in bleeding and vascular injury may not represent current TAVR practice, especially as it pertains to smaller delivery systems and predominant use of transfemoral access.

One of the most important findings of our study relates to readmissions. To our knowledge, this is the first analysis to show that patients undergoing concomitant PCI and TAVR have a lower rate of readmissions within 90 days, compared to patients undergoing PCI followed by TAVR within 30 days. The Centers for Medicare and Medicaid Innovation, part of the Centers for Medicare and Medicaid Services (CMS), have developed the Bundled Payment for Care Improvement Advanced (BPCI-A) model, which unifies payment to physicians and hospitals into a single bundle for a 90-day episode of care²⁸, with the stated goal of incentivizing more efficient use of resources through improvements in coordination of care and quality. Prior analyses have shown that TAVR is associated with lower overall episode payments than SAVR, with higher upfront pre-procedural costs for TAVR that are compensated by lower costs after the procedure²⁹. This was also confirmed by sensitivity analyses that excluded the 90 days prior to the procedure, which is more aligned to the way the BPCI-A model calculates its payments²⁹. Therefore, one of the ways to ensure financial viability of TAVR for healthcare systems is to minimize post-procedural hospitalizations. A single center analysis has shown that bundled claims increased by over 60% in TAVR patients with readmissions³⁰. A national study showed that around a quarter of TAVR patients get readmitted within 90 days and that costs of hospitalization rise by around $5,000 in this group¹⁵. Non-home discharge, which was also seen more frequently in patients undergoing staged PCI and TAVR in our analysis, was also associated with higher rates of readmission¹⁵. Thus, we hypothesize that concomitant PCI and TAVR may offer a unique opportunity to reduce hospitalizations, optimize costs, and increase savings for the healthcare system and, ultimately, patients.

Limitations

Our analysis has limitations. First, this is a retrospective analysis, which limits our ability to assess causality in the PCI timing and outcome relationship. Second, while the NRD is large, it is limited in scope and lacks granularity. For instance, no data on contrast volume is available. Third, the database relies on data reported from ICD codes, which is not adjudicated. Therefore, it is difficult to standardize definitions of the outcomes evaluated in our study. Fourth, data on mortality is not available after discharge, so only in-hospital outcomes and 90-day readmissions were assessed. Finally, differences in outcomes may be related to selection bias. For instance, patients felt to be lower risk may have been more frequently selected for concomitant procedures.

Conclusions

Among TAVR patients with CAD requiring intervention, there were no significant differences in early mortality for patients undergoing concomitant TAVR and PCI or staged procedures. However, there were higher rates of 90-day readmission and acute kidney injury in patients undergoing PCI within 30 days prior to a TAVR procedure, compared with those receiving concomitant PCI and TAVR (Graphical Abstract). Combined PCI and TAVR may offer an opportunity to reduce rehospitalizations and complications in select patients.

Acronyms and Abbreviations

aOR

Adjusted odds ratio

AS

Aortic stenosis

CABG

Coronary artery bypass graft

CI

Confidence interval

HCUP

Healthcare Cost and Utilization Project

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification

ICD-10-PCS

International Classification of Diseases, Tenth Revision, Procedure Coding System

NRD

National Readmissions Database

PCI

Percutaneous coronary intervention

SAVR

Surgical aortic valve replacement

TAVR

Transcatheter aortic valve replacement