Welcome to the STS-ACC TVT Registry Case Scenario, where we will review bleeding and its impact on certain metrics. It is recommended that you pause this case scenario and grab your Executive Summary Measures and Metrics Companion Guide, available on the resource page. An 80-year-old female presented for her transcatheter aortic valve replacement procedure. During the procedure, the transcatheter valve became overmounted on the balloon. Despite multiple attempts, the physician was unable to reposition or retract the valve into the sheath. Thus, the entire system was retracted back to the femoral artery. Suddenly, there was a rapid drop in blood pressure, and quick imaging revealed a tear of the femoral artery. The patient was emergently transfused with two units of packed red blood cells while undergoing emergent surgical vascular repair. The patient's hemoglobin notably dropped four grams. Our question, will this be coded as an access site bleeding event? Number one, no, or number two, yes. Please take a few moments to review the documentation before making a final selection. And the answer is yes. To code bleeding at access site as yes, in sequence 9002, there must first be documentation that the patient experienced a confirmed access site bleeding event between the start of the procedure and until the next procedure or discharge. When this is met, then there must be any one of the following that also occurs between the start of procedure and until the next procedure or discharge, including a hemoglobin drop of three grams or more, or a transfusion of whole blood or packed red blood cells, or a procedural intervention or surgery at the bleeding site to reverse, stop, or correct the bleeding. In this scenario, there was a confirmed access site bleed. Then there was a transfusion of packed red blood cells in addition to surgery at the bleeding site to reverse, stop, or correct the bleeding. Thus, bleeding at access site would be coded as yes. And our next question, using the same scenario, is will this patient appear in the numerator for metric 10062, bleeding disabling? Number one, no, or number two, yes. Please take a few moments to review the documentation before making your final selection. And the answer is number one, no. To meet the numerator, any one of the following criteria needs to be met, including bleeding at the access site, hematoma at access site, retroperitoneal bleed, GI bleed, GU bleed, other bleed, or hemorrhagic stroke, and one of the following, a difference between pre- and post-procedure hemoglobin, five grams or more, or number of units transfused is four units or more, or the patient had an unplanned vascular surgery or intervention and the difference between pre- and post-procedure hemoglobin is five grams or more, or the patient has deceased and their primary cause of death is hemorrhage or cardiovascular hemorrhage. And in this scenario, neither criteria number one, number two, nor number three are met. Therefore, this patient would not appear in the numerator of metric 10.062, bleeding, disabling. And our final question using the same scenario is, will this patient appear as an observed bleed in metric 11711, TAVR 30-day risk standardized mortality morbidity composite? Number one, no, or number two, yes. Please take a few moments to review the documentation before making your final selection. And the answer is number two, yes. An observed bleed is defined as any one of the following. The patient experienced major bleeding or life-threatening bleeding within 30 days of the procedure. The patient had an unplanned vascular surgery or intervention during their hospitalization. And the difference from pre- to post-procedure hemoglobin is three grams or more. There was bleeding at the access site, hematoma at the access site, retroperitoneal bleed, GI bleed, GU bleed, other bleed, or hemorrhagic stroke, and one of the following. The difference between pre- and post-procedure hemoglobin is three grams or more, or the patient was transfused with two units of blood or more. The patient was deceased on discharge due to hemorrhage or cardiovascular hemorrhage. The patient was deceased on follow-up within 30 days of the procedure due to hemorrhage or cardiovascular hemorrhage. And in this scenario, the patient had an unplanned vascular surgery to correct a tear in the femoral artery during their hospitalization. And the difference from pre- to post-procedure hemoglobin was three grams or more. Thus, criteria number two was met. But also, the patient had bleeding at their access site. And the difference between their pre- and post-procedure hemoglobin was three grams or more. And the patient was transfused with two units of blood or more. Thus, criteria number 3A and 3B were met. So you may be asking yourself, how can a patient be included in the numerator for one bleeding metric but not the other bleeding metric? And it is all in the details, details, details. Metric 10062, bleeding-disabling, is only looking at the occurrence of disabling, also known as life-threatening bleeding, which is quantified when there is a drop in hemoglobin of five grams or more or a transfusion of four units of blood or more. This metrics numerator was built referencing the updated standardized endpoint definitions for transcatheter aortic valve implantation, the Valve Academic Research Consortium 2 consensus document. Whereas an observed bleeding metric 11711, TAVR 30-day risk standardized mortality morbidity composite, is looking at both major and disabling bleeding, which is quantified when there is a drop in hemoglobin of three grams or more or a transfusion of two units of blood or more. This model was built referencing the most recent publication, a composite metric for benchmarking site performance in TAVR results from the STS ACC TVT registry. Both resources are available on the resource page of the registry. Thank you for viewing the TVT registry case scenario.

genitourinary bleeding

transcatheter mitral valve repair

hemoglobin levels

cystoscopy

medical coding

transcatheter aortic valve replacement

femoral artery tear

emergency transfusion

access site bleeding

TAVR 30-day risk