Transcatheter Aortic Valve Implantation Program Research Articles

Discharge after TAVI: it can be fast.

Transcatheter aortic valve implantation (TAVI) can now be considered for any patient with symptomatic severe aortic stenosis (AS) who is set to receive an aortic valve replacement with a bioprosthesis1-4. In particular, the recent low-risk trials may dramatically increase the pool of eligible TAVI candidates, with estimates as high as 270,000 patients in Europe and North America5 . The healthcare challenges for heart valve centres are significant. Different levels within a given TAVI programme require restructuring to cope with this changing supply/demand reality at reasonable cost and without concessions in quality. This includes: 1) stronger ties with referral hospitals to relocate preprocedural TAVI work-up outside of the implanting heart valve centres; 2) implementation of local anaesthesia/mild sedation protocols to minimise catheterisation laboratory occupation time; 3) avoidance of unnecessary time spent in intensive care units and general cardiology/cardiac surgery wards, and 4) harmonising institutional logistics

The state of transcatheter aortic valve implantation training in Canadian cardiac surgery residency programs.

The current state of transcatheter aortic valve implantation (TAVI) training for Canadian cardiac surgical residents is unknown. Our goals were to establish a national inventory of TAVI educational resources, elucidate the role of residents in TAVI programs, and determine the attitudes and perspectives of residents and program directors regarding the importance of TAVI technology and training. We sent Web-based surveys and reminders to all Canadian cardiac surgical residents and program directors between February and July 2017. We used descriptive analyses to summarize data in an aggregate and anonymous manner. We analyzed patterned responses to open-ended survey questions using thematic analysis. Seventy-eight of 92 residents (85%) and 11 of 12 program directors (92%) completed the survey, with broad representation from across Canada. A minority of residents (14 [18%]) and program directors (4 [36%]) reported that TAVI training in their program was adequate. Only 3 program directors (27%) reported that their residents had access to TAVI simulation training. Although most residents (76 [97%]) and program directors (10 [91%]) agreed that TAVI was important to the trainee's future practice, about two-thirds (54 [69%] and 7 [64%], respectively) agreed that TAVI should be a focus of fellowship training. A perceived lack of interest from interventional cardiologists to teach surgical residents, competition from TAVI fellows and lack of formalized time during residency were identified as perceived barriers to TAVI training. As Canadian surgical residency training moves toward a Competence by Design curriculum, there remains a pressing need to create uniform learning objectives and expectations in the TAVI curriculum.

EFFECTIVENESS AND LIMITATIONS OF AN EARLY DISCHARGE CARE PATHWAY FOR TRANS-CATHETER AORTIC VALVE RECIPIENTS IN A MODERATE VOLUME CENTRE.

Transcatheter aortic valve implantation (TAVI) has been used increasingly in Canada. Periprocedural care pathways that include conscious sedation and early mobilization designed for safe but early discharge after trans-femoral (TF) TAVI have been developed and validated in large volume centres or multi-centre studies. In our moderate volume TAVI program, an early discharge patient care pathway was progressively instituted in 2015 for TF-TAVI patients. We sought to evaluate its impact on length of stay (LoS) and determine factors precluding early discharge. Clinical and procedural data on patients treated with TAVI in our centre are prospectively collected. To evaluate the impact of the early discharge care pathway on LoS, consecutive patients treated with TF-TAVI and successfully discharged from hospital between 2013 and 2018 were compared across time. Means, medians and proportions were compared with ANOVA, Kruskall-Wallis and Chi-square tests respectively. Clinical and non clinical factors precluding early (< 48h) discharge were retrospectively collected from medical charts. Between January 2013 and February 2018, 171 TF-TAVI were performed in our centre. Of those, 170 were alive at discharge. Baseline characteristics were largely similar to larger TF-TAVI cohorts: mean age 81 ± 8.4 yo, female gender 42%, mean STS score 6.0 ± 4.2. Baseline characteristics did not change across time but for the STS score; STS scores were statistically different on a yearly basis but did not show a downward trend across time. Median LoS decreased significantly from eight days to two days from 2013 to 2016 onward (p < 0.00001). The largest drop in median LoS occurred between 2015 and 2016, from five to two days. Furthermore, 50% of TF-TAVI were successfully discharged on day one after the procedure in 2017, a steep rise from 15% in 2016 and none the previous years. Since 2016, most frequent causes of early discharge failure were conduction abnormalities (30%) and vascular major or minor complications (17%). Among patients not being discharged early, no medical explanation was found in 21% of patients treated before 2016 but only in a single case (3%) in those treated in 2016-18. In a moderate volume Canadian TAVI centre, implementation of an early discharge care pathway is feasible and can be successful with a very limited learning curve. Failure to discharge patients early is most often related to conduction delays or vascular complications. Near abolition of longer LoS not related to medical conditions is feasible.

Updated SICI-GISE position paper on institutional and operator requirements for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of patients with symptomatic severe aortic stenosis and has become the standard of care for inoperable patients and the preferred therapy for those at increased surgical risk with peculiar clinical and anatomic features. Technology advances, growing experience and accumulating data prompted the update of the 2011 Italian Society of Interventional Cardiology (SICI-GISE) position paper on institutional and operator requirements to perform TAVI. The main objective of this document is to provide a guidance to assess the potential of institutions and operators to initiate and maintain an efficient TAVI program.

Viability of a Transcatheter Aortic Valve Implantation Program in a Private Hospital: A Comparison of Two Victorian Hospitals

Background: Transcatheter aortic valve implantation (TAVI) has become an accepted treatment for patients with symptomatic and severe aortic stenosis with increased surgical risk. Currently, there are many public hospitals performing TAVI; however; due to limited funding, there are few private hospitals performing TAVI. This study aimed to compare the TAVI programs at the publicly funded Alfred Hospital (AH) and the private Epworth Hospital (EH).

Advantages of a prospective multidisciplinary approach in transcatheter aortic valve implantation: Eight years of experience

IntroductionAortic stenosis is the most prevalent type of valvular disease in Europe. Surgical aortic valve replacement (SAVR) is the standard therapy, while transcatheter aortic valve implantation (TAVI) is an alternative in patients at unacceptably high surgical risk. Assessment by a heart team is recommended by the guidelines but there is little published evidence on this subject. The purpose of this paper is to describe the experience of a multidisciplinary TAVI program that began in 2008. MethodsThe heart team prospectively assessed 473 patients using a standardized approach. A total of 214 patients were selected for TAVI and 80 for SAVR. Demographic, clinical and procedural characteristics and long-term success rates were compared between the groups. ResultsTAVI patients were older than the SAVR group (median 83 vs. 81 years), and had higher surgical risk scores (median EuroSCORE II 5.3 vs. 3.6% and Society of Thoracic Surgeons score 5.1 vs. 3.1%), as did the patients under medical treatment only. These scores were unable to assess multiple comorbidities. Patients’ outcomes were different between the three groups (mortality with SAVR 25% vs. TAVI 37.6% vs. conservative therapy 57.6%, p=0.001). ConclusionsThe heart team program was able to select candidates appropriately for TAVI, SAVR and conservative treatment, taking into account the risk of both invasive treatments. The use of a prospective standardized heart team approach is recommended, but requires continuous monitoring to ensure effectiveness in a timely manner.

Advantages of a prospective multidisciplinary approach in transcatheter aortic valve implantation: Eight years of experience

IntroductionAortic stenosis is the most prevalent type of valvular disease in Europe. Surgical aortic valve replacement (SAVR) is the standard therapy, while transcatheter aortic valve implantation (TAVI) is an alternative in patients at unacceptably high surgical risk. Assessment by a heart team is recommended by the guidelines but there is little published evidence on this subject. The purpose of this paper is to describe the experience of a multidisciplinary TAVI program that began in 2008. MethodsThe heart team prospectively assessed 473 patients using a standardized approach. A total of 214 patients were selected for TAVI and 80 for SAVR. Demographic, clinical and procedural characteristics and long-term success rates were compared between the groups. ResultsTAVI patients were older than the SAVR group (median 83 vs. 81 years), and had higher surgical risk scores (median EuroSCORE II 5.3 vs. 3.6% and Society of Thoracic Surgeons score 5.1 vs. 3.1%), as did the patients under medical treatment only. These scores were unable to assess multiple comorbidities. Patients’ outcomes were different between the three groups (mortality with SAVR 25% vs. TAVI 37.6% vs. conservative therapy 57.6%, p=0.001). ConclusionsThe heart team program was able to select candidates appropriately for TAVI, SAVR and conservative treatment, taking into account the risk of both invasive treatments. The use of a prospective standardized heart team approach is recommended, but requires continuous monitoring to ensure effectiveness in a timely manner.

Understanding experiences of undergoing transcatheter aortic valve implantation: one-year follow-up.

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for frail, older adults with severe symptomatic aortic stenosis. Although research about long-term clinical outcomes is emerging, there is limited evidence from the perspectives of patients and family caregivers on their perceived benefits and challenges after TAVI. The aim of this study was to describe older adults and family caregivers' perspectives on undergoing TAVI at one year post-procedure. Qualitative description was the method of inquiry. A purposive sample of 31 patients and 15 family caregivers was recruited from a TAVI programme in western Canada. Semi-structured interviews were conducted with participants one year after TAVI. Data were analysed thematically. All participants were satisfied with the decision to undergo TAVI. There were three central themes. First, recovery was experienced in the context of aging and comorbidities, which was shaped by patients' limited options for care and post-procedure symptom burden. Second, reconciling expectations with reality meant that, for some patients, symptom burden remained prevalent and was also influenced by others' expectations. Third, recommendations for recovery related to having information needs met, keeping informed of evolving care processes, and addressing individualised needs for support. The perspectives of participants provide a valuable contribution to the literature about undergoing TAVI. Clinicians need to be attentive to patients' expectations of benefit and temper these with consideration of the individual's broader health situation to provide treatment decision support. Patients and family caregivers also need adequate teaching and support to facilitate safe transition home given the shift towards early discharge after TAVI.

SELECTIVE STRATEGY USING BALLOON-EXPANDABLE VERSUS SELF-EXPANDING TRANSCATHETER AORTIC VALVE PROSTHESIS TO MINIMIZE PARAVALVULAR AORTIC VALVE REGURGITATION

More than mild paravalvular aortic regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) is associated with increased morbidity and mortality. Aortic valve prosthesis sizing by multidetector computed tomography (MDCT) 3-dimensional aortic annular dimensions reduces the incidence of PAR. We hypothesize that MDCT based aortic annular dimensions based strategy selecting balloon expandable (BE) vs. self expanding (SE) aortic valve prosthesis may further reduce the incidence of PAR. We started our TAVI program using BE valves only (Group 1, n=78) with MDCT based aortic annular sizing. We identified that aortic annulus ellipticity ratio (the ratio of the shortest and longest diameter of the aortic annulus) and the degree of aortic prosthesis oversizing [100 × (Prosthetic valve area - aortic annular area) / prosthetic valve area] independently predicted more than mild PAR. In second phase of our TAVI program we used both BE and SE prosthesis. We postulated that a SE prosthesis may conform to the contours of aortic annulus with higher degree of oversizing (DOS), though with less radial force, thereby minimizing risk of annular rupture. We adopted a preferred strategy of using SE prosthesis with aortic annulus ellipticity ratio (AAER) of < 0.7. Group 2 (n=82) comprised of 51 (62.2%) BE valves and 31 (37.8%) SE valves. PAR was assessed by transthoracic echocardiogram done within 30 days of TAVI procedure. In Group 1 with BE valves, AAER of < 0.7 was present in 12.8% of patients with multivariate analysis showing AAER (p=0.02) and DOS (p=0.005) independently predicting PAR. In Group 2 with selective use of BE and SE valves (n=82), AAER was present in 9.8% of patients. None of the patients with BE valves (n=51) had AAER < 0.7 vs. those with SE valves (n=31) AAER < 0.7 was present in 25.8% of patients (p< 0.001). DOS was 11.6% with BE valves and 19.5% with SE valves (p < 0.001). The incidence of more than mild PAR was 12.8% in Group 1. With selective strategy in Group 2 there was no patient with more than mild PAR at 30 days. Subgroup analysis showed similar results for second and third generation BE valves. Selective strategy of using SE valves based on AAER of < 0.7 and careful oversizing of prosthesis was associated with marked reduction in PAR at 30 days. The reduction in PAR is expected to improve clinical outcomes.

THE STATE OF TRANSCATHETER AORTIC VALVE IMPLANTATION TRAINING IN CANADA: A NATIONAL SURVEY OF CARDIAC SURGERY RESIDENTS AND PROGRAM DIRECTORS

The volume of transcatheter aortic valve implantation (TAVI) has increased globally with a subsequent increase in demand for clinicians trained in performing this procedure. However, the state of TAVI training for Canadian cardiac surgical residents is unknown. The objectives of this study were: 1. To establish a national inventory of TAVI educational resources 2. Understand the role of residents in TAVI programs 3. Understand the attitudes and perspectives of residents and program directors (PD). Two National web-based surveys targeting residents and PDs in Royal College of Physicians and Surgeons (Canada) accredited cardiac surgery programs were developed. The survey examined available TAVI educational resources, the attitudes towards TAVI training, and barriers to becoming competent in performing TAVI. An electronic invitation was sent to 100 residents and 12 PDs across Canada between February and April 2017. Descriptive analyses were used to summarize data in an aggregate and anonymous manner. Chi-square testing was used to compare responses between residents and PDs. Thematic analysis using a realist approach was undertaken to analyze patterned responses to open-ended survey questions. 73 of 100 (73%) residents and 10 of 12 (83%) PDs completed the survey. Broad representation from all 12 residency programs across Canada programs and all post-graduate years of training was obtained. A minority of residents (15.1%) and PDs (40%) reported that TAVI training in the their program was adequate (Chi-square(1)=3.692; p=0.055). Only 30% of PDs report that their residents had access to TAVI simulation training. While 98.6% of residents and 90% of PDs agreed that TAVI was important to the trainee’s future practice (Table), 68.5% of residents and 60% of PDs agreed that TAVI should be a focus of fellowship training (Chi-square(1)=0.289; p=0.591). Furthermore, 27.4% of residents and 40% of PDs agreed that there was not enough time in residency to teach TAVI (Chi-square(1)=0.680; p=0.401). Reoccurring patterns from the thematic analysis of barriers to TAVI training were identified as: a perceived lack of interest from interventional cardiologists to teach surgical residents, competition from TAVI fellows, and lack of time (Figure). Educational resources for TAVI training are limited for residents across Canada. While almost all respondents agreed that TAVI will play a vital role in the trainees’ future clinical practice, there are many perceived barriers to providing adequate training during residency. Finally, there is a lack of consensus as to whether TAVI competency should be acquired primarily in residency or fellowship training.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society….

Patients with severe symptomatic aortic stenosis have a poor prognosis with medical management alone, and surgical aortic valve replacement can improve symptoms and survival. In recent years, transcatheter aortic valve implantation (TAVI) has been demonstrated to improve survival in inoperable patients and to be an alternative treatment in patients in whom the risk of surgical morbidity or mortality is high or intermediate. A representative expert committee, summoned by the Association of Cardiovascular Interventions of the Polish Cardiac Society (ACVI) and the Polish Society of Cardio-Thoracic Surgeons, devel-oped this Consensus Statement in transcatheter aortic valve implantation. It endorses the important role of a multi-disciplinary "TAVI team" in selecting patients for TAVI and defines operator and institutional requirements fundamental to the establish-ment of a successful TAVI programme. The article summarises current evidence and provides specific recommendations on organisation and conduct of transcatheter treatment of patients with aortic valve disease in Poland.

Transcatheter Aortic Valve Implantation (TAVI): A Comparison of Public Versus Private Hospital Outcomes

Background: TAVI has become an accepted technique for high-risk patients with severe, symptomatic aortic stenosis (AS). Whilst there are many TAVI programs in public institutions in Australia, due to current funding limitations private hospital TAVI programs remain scarce. We aimed to compare the short-term outcomes between two well established public and private TAVI programs; The Alfred Hospital and Epworth Hospital in Melbourne, Australia. Methods: We describe a prospective observational cohort of 500 patients who underwent TAVI in these hospitals between 2008 and 2016. The same procedural teams operate at both sites. Risk-stratified case selection for TAVI is performed by multidisciplinary Heart Teams at both sites designed to comply with the CSANZ TAVI position statement. Procedural data are stored in a shared TAVI database according to VARC-2 definitions. Results: Over the study period 265 (53%) patients underwent TAVI in the public hospital and 235 (47%) patients in the private hospital. Public patients were slightly younger, median age 84 years (IQR 80,87) vs. median age 85 years (IQR 82,88), p < 0.01. STS scores was similar (4 [IQR 3,6] vs. 4.3 [3,7], p = 0.35). Self-expanding valves were used more frequently overall in both sites (74% vs. 98% p < 0.01), with more balloon expandable valves in public (26% vs. 2%, p < 0.01). All-cause 30-day mortality was very low at both sites (1.9% vs. 0.9%, p = 0.32). Rates of permanent pacemaker (23% vs. 28%, p = 0.26) and length-of-stay (4 [IQR3,7] vs. 5 [IQR 4-7], p = 0.06 days, were also similar. Conclusions: Despite the current funding limitations for TAVI in Australia, comprehensive TAVI programs with excellent clinical outcomes for patients are achievable at both public and private hospitals.

VP05 Comprehensive Evaluation Of An Evolving Transcatheter Technology

INTRODUCTION:Our cardiovascular evaluation unit is mandated to evaluate transcatheter aortic valve implantation (TAVI) in the province of Québec. In 2012, it was recommended that only patients at too high risk for surgery receive TAVI. In partnership with our six hospital TAVI programs, we have measured indicators of structure, process and outcomes since 2013. We are collaborating with multidisciplinary clinical experts to update recommendations for optimal use. Herein, we present the evolving portrait of TAVI in Québec and identify priority issues.METHODS:Clinical data were collected and analyzed for all TAVI performed from 1 April 2013 to 31 March 2016. Regular site feedback was provided. A systematic review of recent guidelines and randomized trials facilitated the interpretation of “real world” results and formulation of provincial quality standards.RESULTS:Provincial TAVI volume increased from 294 in 2013–14 to 340 in 2014–15, and to 360 in 2015–16. Patient age and sex distribution remained relatively constant over time (median age 83 years; 47 percent female). However, the median predicted risk of operative mortality (STS score) decreased in the latest period [6 percent (Interquartile Range, IQR: 4–9) versus 7 percent (IQR: 4–9) versus 4 percent (IQR: 3–7)], suggesting TAVI is increasingly being performed in lower-risk patients. Clinical documentation and processes of care generally improved. Thirty-day mortality decreased (6.1 percent versus 4.1 percent versus 2.8 percent). The literature review identified two central issues: TAVI futility in patients who are too sick and apparent non-inferiority of TAVI compared with surgical valve replacement in medium-risk patients.CONCLUSIONS:Our province-wide TAVI evaluation indicates improving processes and outcomes. Patient selection remains the key in our universal healthcare system, with the need to minimize futile and costly therapy and offer TAVI to those most likely to benefit. Continued monitoring of clinical practice and newly-established quality standards, in close collaboration with clinical teams, remains essential to promote optimal use of this evolving technology.

Nursing leadership of the transcatheter aortic valve implantation Heart Team: Supporting innovation, excellence, and sustainability.

Transcatheter Aortic Valve Implantation (TAVI) is an innovative and resource-intensive treatment of valvular heart disease. Growing evidence and excellent outcomes are contributing to increased patient demand. The Heart Team is foundational to TAVI programs to manage the complexities of case selection and other aspects of care. The competencies and expertise of nurses are well suited to provide administrative and clinical leadership within the TAVI Heart Team to promote efficient, effective, and sustainable program development. The contributions of nursing administrative and clinical leaders exemplify the leadership roles that nurses can assume in healthcare innovation.

Transition to palliative care when transcatheter aortic valve implantation is not an option: opportunities and recommendations.

Purpose of reviewTranscatheter aortic valve implantation (TAVI) is the recommended treatment for most patients with symptomatic aortic stenosis at high surgical risk. However, TAVI may be clinically futile for patients who have multiple comorbidities and excessive frailty. This group benefits from transition to palliative care to maximize quality of life, improve symptoms, and ensure continuity of health services. We discuss the clinical determination of utility and futility, explore the current evidence guiding the integration of palliative care in procedure-focused cardiac programs, and outline recommendations for TAVI programs.Recent findingsThe determination of futility of treatment in elderly patients with aortic stenosis is challenging. There is a paucity of research available to guide best practices when TAVI is not an option. Opportunities exist to build on the evidence gained in the management of end of life and heart failure. TAVI programs and primary care providers can facilitate improved communication and processes of care to provide decision support and transition to palliative care.SummaryThe increased availability of transcatheter options for the management of valvular heart disease will increase the assessment of people with life-limiting conditions for whom treatment may not be an option. It is pivotal to bridge cardiac innovation and palliation to optimize patient outcomes.

0418: Comparison of pre- and post-operative characteristics in octogenarians having isolated surgical aortic valve replacement before versus after introduction of transcatheter aortic valve implantation

Abstract 0418 – Figure Surgical aortic valve replacement (SAVR) is the reference treatment for severe aortic stenosis (AS). Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment. The aim of the study was to assess if the clinical profile of octogenarian patients treated surgically before and after the TAVI program initiation has changed. We retrospectively included consecutive octogenarian patients, who underwent isolated SAVR, between January 2006 and December 2014 in a single high-volume center. We compared preoperative, peri-operative and postoperative characteristics before and after the initiation of TAVI (February 2009). 845 patients were included: 229 in the pre-TAVI group (2006-2008; 3 years), 616 in the post-TAVI group (2009-2014; 6 years). Over time, there was an increased rate of SAVR performed. The mean age was the same, 83.2±2.0 years in the pre-TAVI group, 83.5±2.1 years in the post-TAVI group (p=0.06). The preoperative characteristics were statistically comparable, except for history of heart failure (25% in the pre-TAVI group vs 18% in the post-TAVI group, p=0.04), coronary artery disease (22% in the pre-TAVI group vs 14% in the post-TAVI group, p=0.01), hypertension (59% in the pre-TAVI group vs 68% in the post-TAVI group, p=0.02) and obesity (18% in the pre-TAVI group vs 24% in the post-TAVI group, p=0.03). Peri-operative data and post-operative adverse events were comparable between both groups. The operative mortality (30-day) was similar, 5.2% in the pre-TAVI group, 5.5% in the post-TAVI group (p=0.87). In conclusion, with the emergence of TAVI, the number of octogenarian patients operated on continued to increase, their preoperative characteristics were clinically similar and the operative mortality was stable.

Impact of Hemoglobin Drop, Bleeding Events, and Red Blood Cell Transfusions on Long-term Mortality in Patients Undergoing Transaortic Valve Implantation

BackgroundDespite the minimally invasive nature of transcatheter aortic valve implantation (TAVI), the procedure is associated with several complications. We aimed to analyze the individual impact of bleeding events, hemoglobin (Hb) drop, and red blood cell (RBC) transfusions on prognosis and to evaluate the temporal trends in bleeding and RBC transfusions since the initiation of the TAVI program in our centre and onward. MethodsConsecutive patients (n = 597) undergoing transfemoral TAVI were prospectively enrolled. Periprocedural Hb levels, RBC transfusions, and major/life-threatening bleeding events were documented and analyzed. ResultsIn the entire cohort, mean Hb level decreased after TAVI (11.8 ± 1.4 to 9.5 ± 1.3 g/dL; P < 0.001). Major/life threatening bleeding occurred in 66 (10.1%) patients, and 179 (30%) patients received RBC transfusions. Major/life threatening bleeding was not independently associated with mortality when adjusted for Hb drop and RBC transfusion. Among patients with an Hb drop of < 3 g/dL, those who received RBC transfusions had a higher mortality (hazard ratio [HR], 1.9; confidence interval [CI], 95% CI, 1.2-2.9; P = 0.004). Among patients with an Hb drop of ≥ 3 g/dL, the Hb drop had no significant impact on survival (HR, 1.5; 95% CI, 0.7-2.9; P = 0.2); however, patients who received RBC transfusions had a significantly higher mortality (HR, 4.1; 95% CI, 2.2-7.7; P < 0.001). The use of RBC transfusions decreased gradually over the duration of the study. ConclusionsAn Hb drop is frequently observed after TAVI. RBC transfusions are strongly associated with increased long-term mortality in these patients, regardless of the degree of Hb drop or major bleeding.

Comparison of Inhospital Outcomes of Surgical Aortic Valve Replacement in Hospitals With and Without Availability of a Transcatheter Aortic Valve Implantation Program (from a Nationally Representative Database)

We hypothesized that the availability of a transcatheter aortic valve implantation (TAVI) program in hospitals impacts the overall management of patients with aortic valve disease and hence may also improve postprocedural outcomes of conventional surgical aortic valve replacement (SAVR). The aim of the present study was to compare the inhospital outcomes of SAVR in centers with versus without availability of a TAVI program in an unrestricted large nationwide patient population >50years of age. SAVRs performed on patients aged >50years were identified from the Nationwide Inpatient Sample (NIS) for the years 2011 and 2012 using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. SAVR cases were divided into 2 categories: those performed at hospitals with a TAVI program (SAVR-TAVI) and those without (SAVR-non-TAVI). Atotal of 9,674 SAVR procedures were identified: 4,526 (46.79%) in the SAVR-TAVI group and 5,148 (53.21%) in SAVR-non-TAVI group. The mean age of the study population was 70.2 ± 0.1years with majority (53%) of the patients aged >70years. The mean Charlson's co-morbidity score for patients in SAVR-TAVI group was greater (greater percentage of patients were aged >80years, had hypertension, congestive heart failure, renal failure, and peripheral arterial disease) than that of patients in SAVR-non-TAVI group (1.6 vs 1.4, p<0.001). The propensity score matching analysis showed a statistically significant lower inhospital mortality (1.25% vs 1.72%, p= 0.001) and complications rate (35.6% vs 37.3%, p= 0.004) in SAVR-TAVI group compared to SAVR-non-TAVI group. The mean length of hospital stay was similar in the 2 groups the cost of hospitalization was higher in the SAVR-TAVI group ($43,894 ± 483 vs $41,032 ± 473, p <0.0001). Having a TAVI program was a significant predictor of reduced mortality and complications rate after SAVR in multivariate analysis. In conclusion, this largest direct comparative analysis demonstrates that SAVRs performed in centers with a TAVI program are associated with significantly lower mortality and complications rates compared to those performed in centers without a TAVI program.

Comparison of Preoperative and Postoperative Characteristics in Octogenarians Having Isolated Surgical Aortic Valve Replacement Before Versus After Introduction of Transcatheter Aortic Valve Implantation

Aortic stenosis (AS) is the most frequent heart valve disease. Surgical aortic valve replacement (SAVR) is the reference treatment. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment. New strategies for treating the AS are upcoming. The aim of the study was to assess if the clinical profile of octogenarian patients treated surgically before and after the TAVI program initiation has changed. We retrospectively included consecutive octogenarian patients, who underwent isolated SAVR, from January 2006 to December 2011 in a single high-volume center. We compared preoperative and postoperative characteristics before and after the initiation of TAVI (February 2009). Five hundred seventeen patients were included: 229 in the "pre-TAVI" group (2006 to 2008), 288 in the "post-TAVI" group (2009 to 2011). The mean age was 83.2 ± 2.0 in the "pre-TAVI" group, 83.5 ± 2.1 in the "post-TAVI" group (p= 0.106). There were no significant differences in preoperative characteristics: New York Heart Association class (p= 0.374), history of heart failure (p= 0.680), left ventricular ejection fraction (59.8 ± 12.2% in the "pre-TAVI" group, 59.9 ± 11.3% in the "post-TAVI" group, p= 0.922), coronary artery disease (p=0.431), chronic pulmonary disease (p= 0.363), and previous cardiac surgery (p=0.085). The logistic EuroSCORE was 7.78 ± 4.60% in the "pre-TAVI" group and 7.33 ± 3.96% in the "post-TAVI" group (p= 0.236). The operative mortality (30-day) was comparable: 5.2% in the "pre-TAVI" group, 6.9% in the "post-TAVI" group (p= 0.424). Thus, with the emergence of TAVI, the number of octogenarian patients operated on, their preoperative characteristics, and the operative mortality remained comparable.

Abstract 360: How Should We Measure Quality of Care for Transcatheter Aortic Valve Implantation (TAVI)? Results for 6 Quebec TAVI Programs Compared with International Registries

Background: Our publicly funded cardiology evaluation unit examined quality indicators relating to the use and outcomes of transcatheter aortic valve implantation (TAVI). We compared results in Québec hospitals with registries around the world. Methods: We abstracted data on all TAVI cases (n=294) in 6 hospitals in 2013-14. Variables, outcomes and definitions were chosen to facilitate comparisons with registries. Results were presented to TAVI teams with the goal of choosing quality indicators and improving performance. Results: Annual TAVI center volume ranged from 30 to 115 and rate of TAVI varied widely across Quebec’s 16 health regions, as did rates around the world. Median patient age was 83 years (interquartile range [IQR]: 78-86) with little variation across centers and international registries. Documented proportion of patients with NYHA class III/IV was 64% (188/294) for Quebec and varied from 75 to 86% across registries. A surgical risk score (STS) was recorded in only 53% (156/294) of Quebec patients but was often obligatory in registries. The median STS score for Quebec was very similar to that reported in the USA [6% (IQR: 4-10) vs 7% (IQR: 5-11), respectively] but was much lower than in France, Austria and Brazil. Frequency of in-hospital adverse events varied widely across Québec centers: stroke (0-7.5%), bleeding (16.7-26.7%) and transfusion (16.7-43.3%). Overall incidence of in-hospital stroke was 2.3% (7/294) and varied from 1.8 to 5.3% across registries. Bleeding and transfusion were rarely reported in registries. Conversion to surgery was 3% (9/294) in Quebec, and 0.4-4.3% in registries. In Quebec, 15% of patients required a new pacemaker, with wide variation across centers (0-21%) and registries (6.6-25%). Rates of procedural success varied widely across Quebec, largely due to non-standardized classification of post-TAVI aortic regurgitation. Such classification also varied across registries. Overall procedural success for Quebec (73%; 215/294) was lower than in registries but in the latter, the definition of success was often unclear. In-hospital mortality in Quebec was 6.5% (19/294) versus 5.5% in USA and a reported 5.1% for transvascular and 7.7% for transapical TAVI in Germany. Other registries only reported 30-day mortality, varying from 4.1 to 9.1%. Discharge home was more likely in Quebec (80%) than the USA (63%); this outcome was not reported elsewhere. Conclusions: Practice and outcomes in TAVI vary widely across Quebec hospitals and internationally. Despite publication of recommended endpoints (VARC and BARC), there is a lack of standardized reported outcomes and patient populations. While quality benchmarks for patient selection and outcomes remain unclear, continued monitoring with timely feedback to TAVI teams and decision-makers is essential for this new and costly intervention that is predominantly being performed in the very elderly.