Impact of Malnutrition on Outcomes Following Transcatheter Aortic Valve Implantation (from a National Cohort) Sara Emami, MS, Sarah Rudasill, BA, Nikhil Bellamkonda, BS, Yas Sanaiha, MD, Mario Cale, BS, Josef Madrigal, BS, Nathaniel Christian-Miller, BS, and Peyman Benharash, MD* Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, com- plications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospital- izations. The malnourished cohort included patients with nutritional neglect, cachexia, pro- tein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected out- comes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experi- enced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a signifi- cant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preopera- tive risk stratification and malnutrition modification may improve outcomes in this vulnera- ble population. © 2020 Elsevier Inc. All rights reserved. (Am J Cardiol 2020;00:1-6) Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to open surgery for patients with severe symptomatic aortic stenosis. 1,2 A growing body of research suggests that TAVI is associated with decreased rates of acute kidney injury, atrial fibrillation, and transfu- sion requirements relative to surgical aortic valve replace- ment. 3 Malnutrition is especially prevalent in this high-risk population, with rates as high as 65% in adults >65 years. 4 Malnutrition in older adults undergoing open surgical pro- cedures is associated with increased rates of mortality, read- mission, and longer lengths of hospital stay (LOS) relative to their properly nourished counterparts. 5,6 However, few have examined the association between malnutrition and outcomes following less invasive procedures such as TAVI. A simple method for preoperative nutritional classification before TAVI may allow for better risk assessment and miti- gation. The present study utilized a national cohort to inves- tigate the independent impact of malnutrition on mortality, postoperative complications, discharge location, rates and causes of 30-day readmission, LOS, and total charges fol- lowing TAVI. Methods All adult patients (>18 years) admitted for TAVI were identified using the 2011 to 2016 National Readmission Database. As part of the Healthcare Cost and Utilization Project maintained by the Agency for Healthcare Research and Quality, the National Readmission Database is an all- payer database that provides accurate national estimates for 36 million discharges per year, accounting for 56.6% of all US hospitalizations. Patients without a preoperative diagno- sis of aortic stenosis, and those with endocarditis, a history of valve surgery, or a concurrent cardiac procedure, were excluded (Figure 1). Malnutrition, as defined in the Healthcare Cost and Utili- zation Project, encompassed protein calorie malnutrition, cachexia, nutritional neglect, weight loss secondary to fail- ure to thrive, underweight status, and postsurgical nonab- sorption. 7 A patient was identified as malnourished if they had at least one of the above diagnoses. The International Classification of Diseases - 9/10 codes used to extract these diagnoses are shown in Table 1. The malnourished cohort was further stratified by admission status (elective vs non- elective). Patient and hospital characteristics, co-morbid- ities, and complications were derived from the database in Division of Cardiac Surgery, Cardiovascular Outcomes Research Lab- oratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California. Manuscript received October 29, 2019; revised manuscript received and accepted December 18, 2019. See page 5 for disclosure information. *Corresponding author: Tel: (310) 206-6717; fax: (310) 206-5901. E-mail address: pbenharash@mednet.ucla.edu (P. Benharash). www.ajconline.org 0002-9149/© 2020 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amjcard.2019.12.038 ARTICLE IN PRESS