Early and mid-term outcomes after transcatheter aortic valve implantation (TAVI) in Ireland

Trends in transcatheter aortic valve implantation practice and clinical outcomes at an Irish tertiary referral centre

OBJECTIVE

A paucity of data exists on how transcatheter aortic valve implantation (TAVI) practice has evolved in Ireland. This study sought to analyse temporal trends in patient demographics, procedural characteristics, and clinical outcomes at an Irish tertiary referral centre.

METHODS

The prospective Mater TAVI database was divided into time tertiles based on when TAVI was performed: Group A, November 2008-April 2013; Group B, April 2013-September 2017; and Group C, September 2017-February 2022. Patient and procedural characteristics and clinical outcomes were compared across groups.

RESULTS

A total of 1063 (Group A, 59; Group B, 268; and Group C:, 736) patients were treated with TAVI during the study period (mean age 81.1±7.4, mean Society of Thoracic Surgeons score 5.9±5.1).Conscious sedation (Group A, 0%; Group B, 59.9%; and Group C, 90.2%, p<0.001) and femoral artery access (Group A, 76.3%; Group B, 90.7%; and Group C, 96.6%, p<0.001) were used more frequently over time. The median length of hospital stay reduced from 9 days (IQR 7, 18) in Group A to 2 days (IQR 2, 3) in Group C. In-hospital death was numerically higher in Group A compared with Group C (6.8% vs 1.9%, p=0.078). At 1-year follow-up, the rate of death and/or stroke was similar in Group A and Group C (20.3% vs 12.0%, adjusted HR 1.49, 95% CI (0.59 to 3.74)).

CONCLUSION

There was exponential growth in TAVI procedural volume during the study period. A minimalist approach to TAVI emerged, and this was associated with significantly shorter procedure duration and hospital stay. Clinical outcomes at 1-year follow-up did not change significantly over time.

A survey of general practitioners' knowledge and clinical practice in relation to valvular heart disease

INTRODUCTION

General practice has a key role in diagnosing patients with valvular heart disease (VHD) and referring them to appropriate services.

METHODS

An anonymous survey was conducted to assess the knowledge and clinical practice behaviour of Irish general practitioners (GPs) in relation to VHD. In addition to demographic data, the survey captured information in the following domains: knowledge of VHD prevalence, knowledge of contemporary VHD treatments, barriers to diagnosis, and referral patterns. To augment responses, a monetary prize (donated to charity) was offered and the survey was also disseminated using social media and by the Irish College of General Practitioners.

RESULTS

Valid survey responses were received from 197 GPs. The sample was well-balanced by gender, number of years in practice, and practice setting. A small proportion of GPs (16.8%) used a stethoscope to examine for VHD in all patients over 60 years, a figure that rose to 22.3% in patients over 75. Approximately half of participants (48%) felt confident in their ability to detect and diagnose VHD using a stethoscope, and 74% felt lack of access to echocardiography was a major barrier to making a VHD diagnosis. There was a high level of awareness among GPs of minimally invasive nonsurgical interventions now available for VHD treatment.

DISCUSSION

Irish GPs displayed good understanding of contemporary VHD treatment options but reported low confidence and inconsistent practices in evaluating patients for VHD. Improved access to echocardiography might help address these deficiencies, but reorganisation of services will be required in a resource-limited public health service.

Clinical experience with trans-catheter aortic valve implantation at a tertiary hospital in the Republic of Ireland

INTRODUCTION

There is a paucity of published data on the clinical experience with trans-catheter aortic valve implantation (TAVI) in the Republic of Ireland. We sought to examine the clinical outcomes of patients with medium-term follow-up treated with TAVI at our institution.

METHODS

A prospective TAVI registry was used to assess the baseline demographics, procedural variables and clinical outcomes of patients treated with TAVI between the inception of the programme in 2008 and November 2017.

RESULTS

A total of 354 patients (mean age 80.9 ± 8.1 years, 58% male, mean STS score 6.1 ± 4.3%) were treated during the study period. Major in-hospital outcomes included in-lab death (n = 2, 0.6%), stroke (n = 8, 2.2%), device embolisation (n = 4, 1.2%), permanent pacemaker implantation (n = 22, 6.2%) and major vascular complication (n = 2, 0.6%). The median length of hospital stay was 4 days (IQR 2-8 days). The Kaplan-Meier estimate of freedom from death at 30 days and 1 year for the entire cohort was 97 ± 1% and 85.4 ± 2.3%, respectively. Trans-femoral access was associated with a significantly lower rate of death and/or stroke at 1 year compared to trans-apical access (84.9 ± 2.4% versus 60 ± 8.9%, p = 0.0005). There was no significant difference in freedom from death and/or stroke at 1 year between balloon-expandable and self-expanding valves (81.6 ± 2.6% versus 84.4 ± 7.4%, p = 0.63).

CONCLUSION

This study documents low complication rates and favourable rates of survival following TAVI in a consecutive series of patients undergoing TAVI at a tertiary referral centre in the Republic of Ireland. These data support the application of this therapy in the Irish context.

Alternative Access for Transcatheter Aortic Valve Implantation: Current Evidence and Future Directions

Transcatheter aortic valve implantation (TAVI) is the usual technique for patients with severe aortic stenosis who are at high risk for surgical aortic valve replacement. The transfemoral (TF) route is the most commonly used access type, and significant progress in this procedure has greatly increased the proportion of patients who can undergo it. Not all patients are suitable for TF TAVI, however, so other routes, including transapical, transaortic, subclavian, trans-subclavian/transaxillary, transcarotid and transcaval, may need to be used. Evidence on these routes shows promising results but the majority of this is registry data rather than randomised controlled trials, so TF TAVI remains the safest access route and should be considered for most patients. However, in patients who are unsuitable for TF TAVI, alternative access routes are safe and feasible. The challenges concern choosing the best route, the valve to use and skill of the specialist centre. This article provides a overview of options for alternative vascular access in TAVI, the clinical rationale for using them, current evidence and areas for clinical investigation.

Factors associated with early cardiac complications following transcatheter aortic valve implantation with transapical approach

Purpose

To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TA-TAVI), and to identify factors independently associated with the occurrence of them.

Patients and methods

A retrospective cohort study of 90 patients, who had undergone TA-TAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008–October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital’s electronic database.

Results

The overall 30-day incidence of cardiac complications was estimated at 18.9% (n=17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p=0.01), receiving of oral inotropes preprocedurally (p=0.01), intravenous inotropic support postprocedurally (p=0.01) and requirement for postprocedural tracheal intubation (p=0.001) were the main factors associated with increased probability for patient cardiac morbidity.

Conclusion

It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively.