Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement

[Waiting time to transcatheter aortic valve implantation (TAVI) and mortality during wait period in Algeria]

BACKGROUND

Trans Aortic Valve Implantation (TAVI) has become the primary treatment for aortic stenosis in patients over 75 years old. Despite its clinical efficacy, it's adoption in emerging countries remains low due to the high cost of prostheses and limited healthcare funding resources. This leads to prolonged waiting times for the TAVI procedure, which may lead to complications; these data are missing particularly in emerging countries.

AIMS

To describe waiting time for TAVI and mortality rate in this waiting period.

MATERIALS AND METHODS

This was prospective registry, patients referred for TAVI were prospectively followed; waiting time was calculated from the first visit after referral to TAVI implantation, clinical and, call fellow up was performed every 3 months. We divided patients into two groups: Group 1 (G1) patients still awaiting TAVI (105 patients), and those who underwent TAVI (36 patients). Group 2 (G2) patients who died while awaiting TAVI (16 patients, 10,2 %).

RESULTS

Demographic characteristics were similar, with a tendency for older age in G2 (79.5 ± 5.7 years vs. 82.5 ± 7.4 years, p=0,06). G2 exhibited more left ventricular ejection fraction (LVEF) impairment (8.5% vs. 25%, p=0,03) and a higher rate of severe heart failure with dyspnea stages III or IV (2.8% vs. 12.5%, p<0,001). The mean follow-up in G1 was 242.9 ± 137.4 days; the waiting time for TAVI was 231.7 ± 134.1 days, and the average time between the first consultation and death while awaiting TAVI (G2) was 335.1 ± 167.4 days.

CONCLUSION

in our series, waiting time is high due to limited Trans aortic heart valve availability, mortality during this wait exceeds 10%. Adverse prognostic factors include impaired LVEF and severe dyspnea stages III or IV.

Role of Empagliflozin in heart failure with severe aortic stenosis before valve replacement: EASTER-HF study

We evaluated empagliflozin in severe DAS patients with HF before AVR. HF patients with LVEF 30-80 % and NYHA functional class II-IV symptoms got empagliflozin 10 mg or not within 6 months before AVR, along with SOC. Adding empagliflozin to the SOC before AVR reduced HF death or HHF by 73 % after 6-months in a group of 20 patients (RR 0.27; p = 0.022). Improving LVEF (+3.48 %, p < 0.001) and NT-proBNP levels (-3974.6 pg/mL) with empagliflozin in SOC before AVR significantly reduced in-hospital and 6-month mortality in this patient group. In severe DAS and HF patients, empagliflozin improved symptoms and prognosis.

Transcatheter aortic valve intervention in hospitals without cardiac surgery departments: a future scenario?

Transcatheter aortic valve intervention (TAVI) was introduced in early 2000 to offer treatment to inoperable patients with severe aortic valve stenosis. In a couple of decades, the procedure resulted effective and safe also in patients with intermediate to low risk for surgery; therefore, due to the progressive ageing of the population, the clinical need for TAVI is continuously increasing and is hardly met by the availability of the procedure, the so-called "TAVI capacity". As a result, many patients encounter difficulties in being referred to TAVI centers or face long waiting list times, thus risking severe adverse events (including death) before the procedure is performed. Although contemporary guidelines and consensus documents recommend that TAVI should only be performed in hospitals with active cardiac surgery departments, starting TAVI programs also in interventional cardiac laboratories without on-site cardiac surgery could represent a way to increase TAVI capacity, thus leading to a greater number of patients being treated in less time. On the other side of the coin, such a strategy may jeopardize patient safety in case of periprocedural complications needing bailout surgery and may lead to a suboptimal multidisciplinary Heart Team evaluation. This review aims to assess and discuss available clinical data and implementation of TAVI programs in hospitals without on-site active cardiac surgery departments considering the growing unmet clinical need and technical advancement of TAVI platforms, yet not overlooking the recommendations of international scientific societies.

Transcatheter Aortic Valve Implantation Wait-Time Management: Derivation and Validation of the Canadian TAVI Triage Tool (CAN3T)

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has seen indication expansion and thus exponential growth in demand over the past decade. In many jurisdictions, the growing demand has outpaced capacity, increasing wait times and preprocedural adverse events. In this study, we derived prediction models that estimate the risk of adverse events on the waitlist and developed a triage tool to identify patients who should be prioritized for TAVI.

METHODS AND RESULTS

We included adult patients in Ontario, Canada referred for TAVI and followed up until one of the following events first occurred: death, TAVI procedure, removal from waitlist, or end of the observation period. We used subdistribution hazards models to find significant predictors for each of the following outcomes: (1) all-cause death while on the waitlist; (2) all-cause hospitalization while on the waitlist; (3) receipt of urgent TAVI; and (4) a composite outcome. The median predicted risk at 12 weeks was chosen as a threshold for a maximum acceptable risk while on the waitlist and incorporated in the triage tool to recommend individualized wait times. Of 13 128 patients, 586 died while on the waitlist, and 4343 had at least 1 hospitalization. A total of 6854 TAVIs were completed, of which 1135 were urgent procedures. We were able to create parsimonious models for each outcome that included clinically relevant predictors.

CONCLUSIONS

The Canadian TAVI Triage Tool (CAN3T) is a triage tool to assist clinicians in the prioritization of patients who should have timely access to TAVI. We anticipate that the CAN3T will be a valuable tool as it may improve equity in access to care, reduce preventable adverse events, and improve system efficiency.

Association between social vulnerability index and admission urgency for transcatheter aortic valve replacement

Background

Transcatheter aortic valve replacement (TAVR) are not offered equitably to vulnerable population groups. Adequate levels of insurance may narrow gaps among patients with higher social vulnerability index (SVI). Among a national population of individuals with commercial or Medicare insurance, we sought to determine whether SVI was associated with urgency of receipt of TAVR for aortic stenosis.

Methods and results

Using Optum's de-identified Clinformatics Data Mart Database (CDM), we identified admissions for TAVR with aortic stenosis between January 2018 and March 2022. Admission urgency was identified by CDM claims codes. SVI was cross-referenced to patient zip codes and grouped into quintiles. Generalized linear mixed effects models were used to predict the probability of a TAVR admission being urgent based on SVI quintiles, adjusting for patient and hospital-level covariates.

Results

Among 6680 admissions for TAVR [median age 80 years (interquartile range 75-85), 43.9 % female], 8.5 % (n = 567) were classified as urgent. After adjusting for patient and hospital-level variables, there were no significant differences in the odds of urgent admission for TAVR according to SVI quintiles [OR 5th (greatest social vulnerability) vs 1st quintile (least social vulnerability): 1.29 (95 % CI: 0.90-1.85)].

Conclusions

Among commercial or Medicare beneficiaries with aortic stenosis, SVI was not associated with admission urgency for TAVR. To clarify whether cardiovascular care delivery is improved across SVI with higher paying beneficiaries, future investigation should identify whether relationships between SVI and TAVR urgency vary for Medicaid beneficiaries compared to commercial beneficiaries.

Efficacy and safety of a minimalistic balloon aortic valvuloplasty strategy in a centre without heart surgery

Background

Balloon aortic valvuloplasty (BAV) is a palliative tool for patients with symptomatic severe aortic stenosis (AS) at prohibitive risk for surgery or as a bridge to surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). BAV is traditionally performed in hospitals with onsite cardiac surgery due to its potential complications.

Aims

The aim of this study was to evaluate the safety of BAV procedures performed by trained high-volume operators in a centre without onsite surgery and to assess the effect of a minimalistic approach to reduce periprocedural complications.

Methods

From 2016 to 2021, 187 BAV procedures were performed in 174 patients. Patients were elderly (mean age: 85.0±5.4 years) and had high-risk (mean European System for Cardiac Operative Risk Evaluation score [EuroSCORE] II: 10.1±9.9) features. According to the indications, 4 cohorts were identified: 1) bridge to TAVR (n=98; 56%); 2) bridge to SAVR (n=8; 5%); 3) cardiogenic shock (n=11; 6%); and 4) palliation (n=57; 33%). BAV procedures were performed using the standard retrograde technique via femoral access in 165 patients (95%), although radial access was used in 9 patients (5%). Ultrasound-guided vascular puncture was performed in 118 patients (72%) and left ventricular pacing was administered through a stiff guidewire in 105 cases (60%).

Results

BAV safety was confirmed by 1 periprocedural death (0.6%), 1 intraprocedural stroke (0.6%), 2 major vascular complications (1%) and 9 minor vascular complications (5%). Nine cases of in-hospital mortality occurred (5%), predominantly in patients with cardiogenic shock.

Conclusions

BAV is a safe procedure that can be performed in centres without onsite cardiac surgery using a minimalistic approach that can reduce periprocedural complications.

High-risk admission prior to transcatheter aortic valve replacement and subsequent outcomes

BACKGROUND

Severe, symptomatic aortic stenosis may cause heart failure, acute myocardial infarction, or syncope; limited data exist on the occurrence of such events before transcatheter aortic valve replacement (TAVR) and their impact on subsequent outcomes. Thus, we investigated the association between a preceding event and outcomes after TAVR.

METHODS

From 2014 to 2021 all Danish patients who underwent TAVR were included. Preceding events up to 180 days before TAVR were identified. A preceding event was defined as a hospitalization for heart failure, acute myocardial infarction, or syncope. The 1-year risk of all-cause death, and cardiovascular or all-cause hospitalization was compared for patients with versus without a preceding event using Kaplan-Meier, Aalen-Johansen, and in Cox regression analyses adjusted for patient characteristics.

RESULTS

Of 5,851 patients included, 759 (13.0%) had a preceding event. The median age was 81 years in both groups. Male sex and frailty were more prevalent in patients with a preceding event (males: 64.7% vs 55.2%, frailty: 49.6% vs 40.6%). The most common type of preceding event was a hospitalization for heart failure (n = 524). For patients with a preceding event, the 1-year risk of death was 11.7% (95% CI: 9.4%-14.1%) versus 8.0% (95% CI: 7.2%-8.7%) for patients without. The corresponding adjusted hazard ratio (aHR) was 1.29 (95%CI: 1.01-1.64). Mortality was highest for patients with a preceding event of a heart failure admission (1-year risk: 13.5% [95%CI: 10.5%-16.5%]). Comparing patients with a preceding event to those without, the 1-year risk for cardiovascular rehospitalization was 15.0% versus 8.2% (aHR 1.60 [95%CI: 1.29-1.99]) and 57.6% versus 50.6% for all-cause rehospitalization (aHR 1.08 [95%CI: 0.87-1.20]).

CONCLUSIONS

A hospitalization for heart failure, myocardial infarction, or syncope prior to TAVR was associated with a poorer prognosis and could represent a group to focus resource management on. Interventions to prevent preceding events and improvements in pre- and post-TAVR optimization of these patients are warranted.

Waiting times of women vs. men undergoing transcatheter aortic valve implantation

AIMS

Increasing transcatheter aortic valve implantation (TAVI) rates have resulted in prolonged waiting times. These have been associated with heart failure hospitalizations (HFH) and mortality yet sex differences have not yet been reported.

METHODS AND RESULTS

All patients who underwent TAVI for severe aortic stenosis at a tertiary referral hospital in Australia were prospectively included. Total waiting time was divided into 'work-up' waiting time (period from referral date until heart team approval) and, 'procedural' waiting time (period from heart team approval until procedure date). Patients were analysed according to sex. Cohorts were matched to correct for differences in baseline and procedural variables. The primary endpoints were waiting times. Secondary outcomes included a composite of 30-day mortality and HFH, quality of life, and mobility. A total of 407 patients (42% women) were included. After matching of the two cohorts (345 patients), women had significantly longer total waiting times than men: median 156 [interquartile range (IQR) 114-220] days in women vs. 147 [IQR 92-204] days in men (P = 0.037) including longer work-up (83 [IQR 50-128] vs. 71 [IQR 36-119], P = 0.15) and procedural waiting times (65 [IQR 44-100] vs. 58 [IQR 30-93], P = 0.042). Increasing waiting times were associated with higher 30-day mortality and HFH (P = 0.01 for work-up waiting time, P = 0.02 for procedural waiting time) and decreased 30-day mobility (P = 0.044 for procedural waiting time) in women, but not in men.

CONCLUSION

TAVI waiting times are significantly longer in women compared to men and are associated with increased mortality and HFH and reduced mobility at 30-days.

Cardiac catheterization, coronary intervention, and wait times for transcatheter aortic valve replacement

OBJECTIVES

Prolonged wait times for transcatheter aortic valve replacement (TAVR) are associated with increased morbidity and mortality. The incidence and predictors of short TAVR wait times (STWT: defined as ≤ 30 days from referral to TAVR procedure) have not been defined. This study examined the impact of clinical characteristics, demographics, and pre-TAVR cardiac catheterization on wait times for TAVR.

METHODS

This was a retrospective observational analysis of 831 patients with severe aortic stenosis undergoing TAVR from 2019 to mid-2022 at the University of Vermont Medical Center. Demographics, timing of treatment [stratified by COVID-19 onset (1 March 2020)], TAVR center travel distance, baseline clinical factors, and process-related variables were analyzed to determine univariate STWT predictors (P < 0.10). Multivariable analysis was performed to determine independent STWT predictors.

RESULTS

Approximately 50% of TAVR patients in this study achieved a STWT. The proportion of patients with STWT was higher (54.7% vs. 45.2%; P = 0.008) after the onset of COVID-19 pandemic. STWT was not related to travel distance (P = 0.61). Patients with left ventricular ejection fraction (LVEF) > 60% were less likely to achieve STWT compared to patients with LVEF < 40% (OR 0.45, P = 0.003). Patients who required catheterization or percutaneous coronary intervention (PCI) before TAVR were significantly less likely to achieve STWT (OR 0.65, P = 0.01).

CONCLUSION

TAVR wait times were not affected by the COVID-19 pandemic or single rural TAVR center travel distance. Sicker patients were more likely to achieve STWT while catheterization/PCI before TAVR was associated with longer wait times.

Health Care Resource, Economic, and Readmission Implications After Acute Decompensated Aortic Stenosis-A Nationwide Study

Acute decompensated aortic stenosis (ADAS) is common. The cumulative burden of ADAS from a clinical, health care resource, and financial perspective is unknown. This study sought to assess the national impact of ADAS compared with electively treated, stable patients with aortic stenosis (non-ADAS). Using the National Readmissions Database between 2016 and 2019, patients with ADAS and non-ADAS were identified using International Classification of Diseases, Tenth Revision codes. Patients with ADAS were propensity-matched to non-ADAS patients (1:2) using age, gender, and Charlson co-morbidity index. We compared in-hospital mortality, length of stay (LOS), health care-associated costs, and 90-day readmission data between the 2 cohorts. A total of 51,498 propensity-matched patients were included in this study: median age 75 years, 64% men. The in-hospital mortality for ADAS was higher than non-ADAS (2.8% vs 1.5%, p <0.0001). The LOS during the index admission was longer for ADAS (9 [5 to 13] vs 4 [2 to 6] days, p <0.0001). The health care-associated costs per patient was greater for ADAS ($55,450.0 [41,860.4 to 74,500.7] vs $43,405.7 [34,218.5 to 56,034.8], p <0.0001). Readmission to hospital within 90 days was more frequent in ADAS (21.1 vs 16.8%, p <0.001). The in-hospital mortality during readmission was higher with ADAS (3.9% vs 2.8%, p = 0.004). The readmission LOS was longer with ADAS (4 [2 to 7] vs 3 [2 to 6] days, p <0.0001). In conclusion, ADAS imposes a significant burden clinically and financially and on health care resources compared with non-ADAS during the index admission and 90-day follow-up. There is an urgent need to predict ADAS and optimize the timing of aortic valve replacement to reduce the incidence and the burden associated with ADAS.

Predictors of worse outcome after postponing non-emergency cardiac interventions during the COVID-19 pandemic

OBJECTIVE

Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalisation. This study aimed to identify predictors of worse clinical outcome after deferral of non-emergency cardiovascular interventions.

METHODS

This observational case-control study included consecutive patients whose non-emergency cardiac intervention has been postponed during COVID-19-related lockdown between 19 March and 30 April 2020 (n=193). Cox regression was performed to identify predictors of the combined 1-year end point emergency cardiovascular hospitalisation and death. All patients undergoing non-emergency interventions in the corresponding time period 2019 served as control group (n=216).

RESULTS

The combined end point of death and emergency cardiovascular hospitalisation occurred in 70 (36.3%) of 193 patients with a postponed cardiovascular intervention. The planned intervention was deferred by a median of 23 (19-36) days. Arterial hypertension (HR 2.27; 95% CI 1.00 to 5.12; p=0.049), chronic kidney disease (HR 1.89; 95% CI 1.03 to 3.49; p=0.041) as well as severe valvular heart disease (HR 3.08; 95% CI 1.68 to 5.64; p<0.001) were independent predictors of death or emergency hospitalisation. Kaplan-Maier estimators of the combined end point were 31% in patients with arterial hypertension, 56% in patients with severe valvular heart disease and 77% with both risk factors (HR 12.4, 95% CI 3.8 to 40.7; p<0.001) and only 9% in patients without these risk factors (log rank p<0.001). N-terminal pro-B-type natriuretic peptide (NT-proBNP) cut-point of ≥1109 pg/mL best predicts the occurrence of primary end point event in deferred patients (area under the curve 0.71; p<0.001; sensitivity 63.8%, specificity 69.4%).

CONCLUSION

Our results suggest that patients with either arterial hypertension, chronic kidney or severe valvular heart disease are at very high risk for emergency hospitalisation and increased mortality in case of postponed cardiac interventions even in supposed stable clinical status. Risk seems to be even higher in patients suffering from a combination of these conditions. If the ongoing or future pandemics force hospitals again to postpone cardiac interventions, the biomarker NT-proBNP is an applicable parameter for outpatient monitoring to identify those at risk for adverse cardiovascular events.

Time From First Contact With Heart Team to Transcatheter Aortic Valve Replacement in the COVID-19 Era

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) has become the dominant form of aortic valve replacement in the United States. During the Coronavirus disease 2019 (COVID-19) pandemic, access to elective surgical care was decreased, particularly for TAVR patients. In this study, we examine the impact of each COVID-19 "wave," on our patient's access to TAVR procedures and their associated outcomes.  Methods: After institutional review board approval, we conducted a retrospective review of a prospectively maintained database and a review of our own center's database to assess time to TAVR pre-COVID-19 and during internally defined COVID-19 "waves." Statistical analysis was conducted via a t-test.

RESULTS

We measured the time from first contact to TAVR and compared each COVID-19 wave to our institution's pre-COVID-19 data. During Wave 1 and 2 of COVID-19, our mean time to TAVR increased significantly to 68.44 ± 48.66 days (p = 0.05) and 68.94 ± 53.16 days (p = 0.02), respectively. All three COVID-19 waves demonstrated a statistically significant increase in all-cause mortality post-operatively (PO) with mean PO mortality of 2.5 (p = 0.0035), 1.33 (p = 0.0009), and 0.67 (p = 0.006), respectively, compared to pre-COVID-19 data.  Conclusions: Multiple studies have shown that increased time from first contact to TAVR results in increased morbidity and mortality. COVID-19 increased our institution's time to TAVR significantly across two waves with an increase in all-cause mortality in each wave. This study highlights the importance that institutions should develop mechanisms to ensure access to care during crises so that patients do not face potentially avoidable harm.

Regional Differences in Outcomes for Patients Undergoing Transcatheter Aortic Valve Replacement in New York State and Ontario

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR among jurisdictions. It is unknown if such variation is associated with differences in postprocedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high vs low access of care to TAVR translate to differences in postprocedural outcomes.

METHODS

In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1, 2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all-cause readmissions. Using indirect standardization, we calculated the observed vs expected outcomes for New York patients, had they been treated in Ontario.

RESULTS

Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5% of New York patients. With adjustment, this translated to an observed-expected ratio of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients.

CONCLUSIONS

Having greater access to TAVR may be associated with improved outcomes, potentially because of intervention earlier in the trajectory of the disease.

National Trends of Structural Heart Disease Interventions from 2016 to 2020 in the United States and the Associated Impact of COVID-19 Pandemic

The Coronavirus Disease-2019 (COVID-19) pandemic placed an enormous strain on the healthcare system. Data on the impact of COVID-19 on the utilization and outcomes of structural heart disease interventions in the United States are scarce. The National Inpatient Sample from 2016 to 2020 was queried to identify adult admissions for transcatheter aortic valve replacement (TAVR), left atrial appendage occlusion (LAAO), and transcatheter end-to-end repair (TEER). The primary outcome was temporal trends of procedure utilization rate per 100,000 admissions over quarters from 2016 to 2020. The secondary outcomes were adjusted rates of in-hospital mortality, major complications, and length of stay (LOS). Among 434,630 weighted admissions (TAVR: 305,550; LAAO: 89,300; TEER: 40,160), 95,010 admissions (22%) were during the COVID-19 era. There was a decline during the second quarter of 2020 followed by an increase to the pre pandemic levels (TAVR: 220 to 253, LAAO: 57 to 109, and TEER: 31 to 36 per 100,000 admissions, Ptrend<0.001). There were no differences in the mortality or major complication rates. Median LOS has decreased in TAVR (4 days-1 day) and in TEER (3 days-1 day) but remained stable in LAAO (1 day). This nationwide analysis showed that structural heart disease interventions decreased during the early waves of COVID-19 pandemic. There was a significant reduction in hospital LOS without differences in in-hospital mortality or complication rates during the pandemic. These data suggest that hospitals adapted to the unprecedent challenges during the pandemic to provide advanced cardiac care to patients.

Regional Variation in the Use and Outcomes of Transcatheter Aortic Valve Replacement in California

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has been widely adopted for management of aortic stenosis. The purpose of this study was to examine regional access to and outcomes following TAVR in California.

METHODS

Patients undergoing TAVR or isolated surgical aortic valve replacement (SAVR) from 2008 to 2019 in California were identified in the Office of Statewide Health Planning and Development database. California was divided into seven regions: Northern California, San Francisco Bay Area, Central California, Los Angeles, Inland Empire, Orange, and San Diego. Regional TAVR volumes were normalized to Medicare beneficiaries or isolated SAVR volume. Outcomes included risk-adjusted 30-day mortality and major adverse cardiovascular and cerebral events (MACCE). Trends were studied using non-parametric tests, and regional outcomes using logistic regression.

RESULTS

TAVR volume increased annually since 2011, with 7148 cases performed in California in 2019. After normalization, variation in utilization of TAVR was evident, with the least performed in Central California. TAVR to SAVR ratios in 2019 were greatest in Northern California, Los Angeles, and San Diego, and least in the Inland Empire. After risk adjustment, there were no significant regional differences in 30-day mortality, but lower 30-day MACCE in the San Francisco Bay Area.

CONCLUSIONS

Regional differences in TAVR utilization exist, with limited access in Central California and the Inland Empire, but risk-adjusted outcomes are similar. Efforts to reach underserved areas through existing program expansion or regional referrals may distribute transcatheter technology more equitably across California.

Deferral of Non-Emergency Cardiovascular Interventions Triggers Increased Cardiac Emergency Admissions-Analysis of the COVID-19 Related Lockdown

BACKGROUND

Data on the relation between non-emergency and emergency cardiac admission rates during the COVID-19 lockdown and post-lockdown period are sparse.

METHODS

Consecutive cardiac patients admitted to our tertiary heart center between 1 January and 30 June 2020 were included. The observation period of 6 months was analyzed in total and divided into three defined time periods: the pre-lockdown (1 January-19 March), lockdown (20 March-19 April), and post-lockdown (20 April-30 June) period. These were compared to the reference periods 2019 and 2022 using daily admission rates and incidence rate ratios (IRR).

RESULTS

Over the observation period from 1 January to 30 June, cardiac admissions (including non-emergency and emergency) were comparable between 2019, 2020, and 2022 (n = 2889, n = 2952, n = 2956; p = 0.845). However, when compared to the reference period 2019, non-emergency admissions decreased in 2020 (1364 vs. 1663; p = 0.02), while emergency admissions significantly increased (1588 vs. 1226; p < 0.001). Further analysis of the lockdown period revealed that non-emergency admissions dropped by 82% (IRR 0.18; 95%-CI 0.14-0.24; p < 0.001) and 42% fewer invasive cardiac interventions were performed (p < 0.001), whereas the post-lockdown period showed a 52% increase of emergency admissions (IRR 1.47; 95%-CI 1.31-1.65; p < 0.001) compared to 2019.

CONCLUSIONS

We demonstrate a drastic surge of emergency cardiac admissions post-COVID-19 related lockdown suggesting that patients who did not keep their non-emergency appointment had to be admitted as an emergency later on.

Procedural and long-term outcome among patients undergoing expedited trans-catheter aortic valve replacement

OBJECTIVE

Patients with rapidly deteriorating clinical status due to severe aortic stenosis are often referred for expedited transcatheter aortic valve replacement (TAVR). Data regarding the outcome of such interventions is limited. We aimed to evaluate the outcome of patients undergoing expedited TAVR.

DESIGN AND SETTING

Data were derived from the Israeli Multicenter Registry.

SUBJECTS

Subjects were divided into two groups based on procedure urgency: patients who were electively hospitalized for the procedure (N = 3140) and those who had an expedited TAVR (N = 142). Procedural and periprocedural complication rates were significantly higher among patients with an expedited indication for TAVR compared to those having an elective procedure: valve malposition 4.6% versus 0.6% (p &lt; 0.001), procedural cardiopulmonary resuscitation 4.3% versus 1.0% (p = 0.007), postprocedure myocardial infarction 2.0% versus 0.4% (p = 0.002), and stage 3 acute kidney injury 3.0% versus 1.1%, (p &lt; 0.001). Patients with expedited indication for TAVR had significantly higher in hospital mortality (5.6% vs. 1.4%, p = 0.003). Kaplan-Meier's survival analysis showed that patients undergoing expedited TAVR had higher 3-year mortality rates compared to patients undergoing an elective TAVR procedure (p &lt; 0.001). Multivariate analysis found that patients with expedited indication had fourfolds increased risk of in-hospital mortality (odds ratio: 4.07, p = 0.001), and nearly twofolds increased risk of mortality at 3-year (hazard ratio: 1.69, p = 0.001) compared to those having an elective procedure.

CONCLUSION

Patients with expedited indications for TAVR suffer from poor short- and long-term outcomes. It is important to characterize and identify these patients before the deterioration to perform TAVR in a fast-track pathway to minimize their procedural risk.

The Road to a Transcatheter Edge to Edge Repair: Patient Experiences Leading Up to the Procedure and in the Early Recovery Period

AIM

Mitral valve transcatheter edge-to-edge repair (TEER) is a minimally invasive treatment option for patients with severe symptomatic mitral regurgitation who are at increased risk for cardiac surgery and are receiving optimal medical therapy. Little is known about patients' perspectives of their journey of care, including their experiences leading up to treatment, and their early recovery period. The aim of this study was to explore patients' experiences of their journey to TEER and their perspectives on their early recovery.

METHODS AND RESULTS

We conducted a qualitative study using interpretive description. A purposive sample of 12 patients, 3 to 6 months post TEER procedure, were recruited from a tertiary hospital. The median age was 79 years and 7 were male and 5 were female. Data collection included semi-structured interviews via the telephone. Data analysis followed an iterative process and utilized thematic analysis. There were four central themes highlighting the experiences of the patients leading up to their procedure: (1) escalating challenges with everyday life; (2) plummeting losses; (3) choosing and readiness to proceed with TEER; and (4) the long and uncertain wait. The theme improved health status highlights the experiences of patients in their early recovery.

CONCLUSION

Patients' experiences of waiting for TEER are complex and involve multifaceted challenges related to their worsening cardiac symptoms and navigating the health care system. Care pathways must be in place to provide continuity of care and support.

Patient- and Process-Related Contributors to the Underuse of Aortic Valve Replacement and Subsequent Mortality in Ambulatory Patients With Severe Aortic Stenosis

Background

Many patients with severe aortic stenosis (AS) and an indication for aortic valve replacement (AVR) do not undergo treatment. The reasons for this have not been well studied in the transcatheter AVR era. We sought to determine how patient‐ and process‐specific factors affected AVR use in patients with severe AS.

Methods and Results

We identified ambulatory patients from 2016 to 2018 demonstrating severe AS, defined by aortic valve area ≤1.0 cm². Propensity scoring analysis with inverse probability of treatment weighting was used to evaluate associations between predictors and the odds of undergoing AVR at 365 days and subsequent mortality at 730 days. Of 324 patients with an indication for AVR (79.3±9.7 years, 57.4% men), 140 patients (43.2%) did not undergo AVR. The odds of AVR were reduced in patients aged >90 years (odds ratio [OR], 0.24 [95% CI, 0.08–0.69]; P=0.01), greater comorbid conditions (OR, 0.88 per 1‐point increase in Combined Comorbidity Index [95% CI, 0.79–0.97]; P=0.01), low‐flow, low‐gradient AS with preserved left ventricular ejection fraction (OR, 0.11 [95% CI, 0.06–0.21]), and low‐gradient AS with reduced left ventricular ejection fraction (OR, 0.18 [95% CI, 0.08–0.40]) and were increased if the transthoracic echocardiogram ordering provider was a cardiologist (OR, 2.46 [95% CI, 1.38–4.38]). Patients who underwent AVR gained an average of 85.8 days of life (95% CI, 40.9–130.6) at 730 days.

Conclusions

The proportion of ambulatory patients with severe AS and an indication for AVR who do not receive AVR remains significant. Efforts are needed to maximize the recognition of severe AS, especially low‐gradient subtypes, and to encourage patient referral to multidisciplinary heart valve teams.

Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalizations

Background

During the COVID-19 pandemic, in anticipation of a demand surge for high-care hospital beds, many hospitals postponed non-emergency interventions of cardiac patients.

Aim

The aim of this study was to assess the outcomes of cardiac patients whose non-emergency interventions had been deferred during the COVID-19 pandemic.

Methods

Patients whose non-emergency cardiac intervention had been cancelled between March 19th and April 30th, 2020 were included (study group). All patients were considered as deferrable according to current recommendations. Patients’ outcomes after 12 months were compared to a seasonal control group who underwent non-emergency interventions in 2019 as scheduled. The primary endpoint was a composite of emergency cardiovascular hospitalization and death. Secondary endpoints were levels of symptoms and cardiac biomarkers.

Results

Outcomes of 193 consecutive patients in the study group were assessed and compared to 216 controls. The primary endpoint occurred significantly more often in the study group (HR 2.42, 95%CI 1.63–3.61, p < 0.001). This was driven by an increase in hospitalizations. Subgroup analyses showed that especially patients with a deferred transcatheter heart valve intervention experienced early emergency hospitalization (HR 9.55, 95%CI 3.70–24.62, p < 0.001). These findings were accompanied by more pronounced symptoms and higher biomarker levels.

Conclusions

Deferral of non-emergency cardiac interventions to meet the higher demand for hospital beds during the COVID-19 crisis is associated with early emergency cardiovascular hospitalizations. Patients suffering from valvular heart disease especially constitute a vulnerable group. Consequently, our results suggest that current recommendations on the management of cardiovascular disease during the COVID-19 pandemic need revision.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-02032-z.

Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis

Background

Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost‐effective investment in TAVI care that should be made at a health system level to meet quality indicator goals.

Methods and Results

We performed a cost‐utility analysis using probabilistic patient‐level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2‐year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting ≥1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per‐person costs, quality‐adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost‐effectiveness thresholds between $0 and $100 000 per quality‐adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ≈26 wait‐list deaths and 200 wait‐list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ≈$14 to ≈$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost‐effective.

Conclusions

This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care.

Impact of wait times on late postprocedural mortality after successful transcatheter aortic valve replacement

Wait times are associated with mortality on waiting list for transcatheter aortic valve replacement (TAVR). Whether longer wait times are associated with long term mortality after successful TAVR remains unassessed. Consecutive patients successfully treated with elective TAVR in our center between January 2013 and August 2019 were included. The primary end point was one-year all-cause mortality. TAVR wait times were defined as the interval from referral date for valve replacement to the date of TAVR procedure. A total of 383 patients were included with a mean wait time of 144.2 ± 83.87 days. Death occurred in 55 patients (14.4%) at one year. Increased wait times were independently associated with a relative increase of 1-year mortality by 2% per week after referral (Adjusted Hazard Ratio 1.02 [1.002–1.04]; p = 0.02) for TAVR. Chronic kidney disease, left ventricular ejection fraction ≤ 30%, access site and STS score were other independent correlates of 1-year mortality. Our study shows that wait times are relatively long in routine practice and associated with increased 1-year mortality after successful TAVR. Such findings underscore the need of strategies to minimize delays in access to TAVR.

Can transcatheter aortic valve implantation [TAVI] be performed at institutions without on-site cardiac surgery department?

Transcatheter aortic valve implantation [TAVI] represents a paradigm shift in therapeutic options for patients with severe aortic stenosis [AS]. In less than 20 years, TAVI has rapidly disseminated to include a significant proportion of AS patients. The number of AS patients needing TAVI is expected to further increase. Since there is a limited number of centers performing TAVI, wait times are expected to increase. This might have a critical impact of AS patient life as mortality rate of AS patients awaiting TAVI, is substantial, ranging from 2 to 10%. With time, as more patients were treated, improved experience, better imaging and devices, this technology became safer with more reliable results. Today most TAVI complications are related to vascular access [4-6%] and there is less need for emergency thoracic bail out [0.2-0.5%]. In this review, we summarize the prognosis while waiting, the outcomes of patients undergoing TAVI at institutions without on-site cardiac surgery departments and the data describing rates and outcomes of TAVI patients requiring treatment of intra-procedural life-threatening complications. Similar to coronary interventions in the past, TAVI should be considered also in centers without on-site cardiac surgery departments under certain conditions such as, experienced operators, heart team discussion, well established imaging modalities, skilled and qualified support personal, and adequate pre- and post-care facility.

Cardiovascular procedural deferral and outcomes over COVID-19 pandemic phases: A multi-center study

BACKGROUND

The COVID-19 pandemic has disrupted routine cardiovascular care, with unclear impact on procedural deferrals and associated outcomes across diverse patient populations.

METHODS

Cardiovascular procedures performed at 30 hospitals across 6 Western states in 2 large, non-profit healthcare systems (Providence St. Joseph Health and Stanford Healthcare) from December 2018-June 2020 were analyzed for changes over time. Risk-adjusted in-hospital mortality was compared across pandemic phases with multivariate logistic regression.

RESULTS

Among 36,125 procedures (69% percutaneous coronary intervention, 13% coronary artery bypass graft surgery, 10% transcatheter aortic valve replacement, and 8% surgical aortic valve replacement), weekly volumes changed in 2 distinct phases after the initial inflection point on February 23, 2020: an initial period of significant deferral (COVID I: March 15-April 11) followed by recovery (COVID II: April 12 onwards). Compared to pre-COVID, COVID I patients were less likely to be female (P = .0003), older (P < .0001), Asian or Black (P = .02), or Medicare insured (P < .0001), and COVID I procedures were higher acuity (P < .0001), but not higher complexity. In COVID II, there was a trend toward more procedural deferral in regions with a higher COVID-19 burden (P = .05). Compared to pre-COVID, there were no differences in risk-adjusted in-hospital mortality during both COVID phases.

CONCLUSIONS

Significant decreases in cardiovascular procedural volumes occurred early in the COVID-19 pandemic, with disproportionate impacts by race, gender, and age. These findings should inform our approach to future healthcare disruptions.

The Impact of the COVID-19 Pandemic on Cardiac Procedure Wait List Mortality in Ontario, Canada

Background

The novel SARS-CoV-2 (COVID-19) pandemic has dramatically altered the delivery of healthcare services, resulting in significant referral pattern changes, delayed presentations, and procedural delays. Our objective was to determine the effect of the COVID-19 pandemic on all-cause mortality in patients awaiting commonly performed cardiac procedures.

Methods

Clinical and administrative data sets were linked to identify all adults referred for: (1) percutaneous coronary intervention; (2) coronary artery bypass grafting; (3) valve surgery; and (4) transcatheter aortic valve implantation, from January 2014 to September 2020 in Ontario, Canada. Piece-wise regression models were used to determine the effect of the COVID-19 pandemic on referrals and procedural volume. Multivariable Cox proportional hazards models were used to determine the effect of the pandemic on waitlist mortality for the 4 procedures.

Results

We included 584,341 patients who were first-time referrals for 1 of the 4 procedures, of whom 37,718 (6.4%) were referred during the pandemic. The pandemic period was associated with a significant decline in the number of referrals and procedures completed compared with the prepandemic period. Referral during the pandemic period was a significant predictor for increased all-cause mortality for the percutaneous coronary intervention (hazard ratio, 1.83; 95% confidence interval, 1.47-2.27) and coronary artery bypass grafting (hazard ratio, 1.96; 95% confidence interval, 1.28-3.01), but not for surgical valve or transcatheter aortic valve implantation referrals. Procedural wait times were shorter during the pandemic period compared with the prepandemic period.

Conclusions

There was a significant decrease in referrals and procedures completed for cardiac procedures during the pandemic period. Referral during the pandemic was associated with increased all-cause mortality while awaiting coronary revascularization.

Structural Heart Interventions During COVID-19

The spread of Coronavirus Disease 2019 (COVID-19) pandemic across the globe and the United States presented unprecedented challenges with dawn of new policies to reserve resources and protect the public. One of the major policies adopted by hospitals across the nations were postponement of non-emergent procedures such as transaortic valve replacement (TAVR), left atrial appendage closure device (LAAC), MitraClip and CardioMEMS. Guidelines were based mainly on the avoidable clinical outcomes occurring during COVID-19 era. As our understanding of the SARS-CoV-2 evolved, advanced cardiac procedures may safely continue through careful advanced coordination. We aim to highlight the new guidelines published by different major cardiovascular societies, and discuss solutions to safely perform procedures to improve outcomes in a patient population with high acuity of illness during the COVID-19 pandemic era.

Modeling the Impact of Delaying TAVR for the Treatment of Aortic Stenosis in the Era of COVID-19

Objective

The aim of this study was to model the short term and 2-year overall survival for intermediate- and low-risk patients with severe symptomatic AS undergoing timely or delayed transcatheter aortic valve replacement during the 2019 novel coronavirus pandemic.

Methods

We developed a decision analysis model to evaluate two treatment strategies for both low-risk and intermediate-risk patients with aortic stenosis during the 2019 novel coronavirus pandemic.

Results

Prompt transcatheter aortic valve replacement resulted in improved 2-year overall survival when compared to delayed intervention for intermediate-risk patients (0.81 versus 0.67) and low-risk patients (0.95 vs 0.85), due to the risk of death or the need for urgent/emergent transcatheter aortic valve replacement in the waiting period. However, if the probability of acquiring the 2019 novel coronavirus is greater than 55% (intermediate risk patients) or 47% (low risk patients), delayed transcatheter aortic valve replacement is favorable to prompt intervention (0.66 vs 0.67, intermediate risk; 0.84 vs 0.85, low risk).

Conclusions and Relevance

Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe aortic stenosis results in improved 2-year survival when local healthcare system resources are not significantly constrained by the 2019 novel coronavirus.

Indirect Impact of the COVID-19 Pandemic on Activity and Outcomes of Transcatheter and Surgical Treatment of Aortic Stenosis in England

Supplemental Digital Content is available in the text.

Aortic stenosis requires timely treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This study aimed to investigate the indirect impact of coronavirus disease 2019 (COVID-19) on national SAVR and TAVR activity and outcomes.

Real-World Health-Economic Considerations Around Aortic-Valve Replacement in a Publicly Funded Health System

Herein, we describe the unique interplay among biomedical ethics, principles of distributive justice, and economic theory to highlight the role of health technology assessments to compare therapeutic options for aortic valve replacement. From the perspective of the Canadian health care system, transcatheter aortic-valve implantation is associated with higher costs but also higher incremental health benefits compared with surgical aortic-valve replacement. At current willingness to pay thresholds, transcatheter aortic-valve replacement is likely cost effective across the spectrum of risk, from inoperable patients to those at low surgical risk. However, we highlight the nuances within each subgroup of surgical risk that merit careful consideration by the heart team. Moreover, incorporation of patients and their preferences in decision-making is key. In particular, in young, low-risk patients, there remains uncertainty regarding the optimal treatment, with unique concerns around valve durability, selection of valve prosthesis, and consideration for special procedures such as the Ross procedure. Nonetheless, current research suggests that, universally, patients prefer a less invasive approach compared with a more invasive approach. Finally, we highlight that there remain critical issues around timeliness of access to care and unacceptable geographic inequities across Canada. Further research into alternative funding mechanisms and integrated cross-sector care pathways is necessary to address these issues.

Personalized teleprehabilitation in elective cardiac surgery: a study protocol of the Digital Cardiac Counselling randomized controlled trial

Aims

Previous research has shown the possibility to use the pre-operative period to improve a patient's tolerance for surgery. However, there is limited experience with prehabilitation in cardiac surgery. The aim of this study is to evaluate the effect of a comprehensive personalized teleprehabilitation programme on major adverse cardiac events (MACE) in patients scheduled for elective cardiac surgery. Secondary outcomes are post-operative complications, cardiovascular risk factors, quality of life, and cost-effectiveness.

Methods and results

In this single-centre randomized controlled trial, patients are eligible for inclusion when they are ≥18 years of age and cardiac surgery is scheduled at least 8 weeks from informed consent. Participants will be randomized to the teleprehabilitation group or the control group. After a digital baseline screening for perioperative risk factors, patients in the intervention arm can pre-operatively be referred to one or more of the prehabilitation modules (functional exercise training, inspiratory muscle training, psychological support, nutritional support, and/or smoking cessation). The programme is targeted at a duration of at least 6 weeks. It is executed by a multidisciplinary team using (video)calls and supported by a custom-made digital platform. During the pre-operative period, the platform is also used to inform patients about their upcoming surgery and for telemonitoring.

Conclusion

Reducing perioperative risk factors might result in a reduction of MACE, post-operative complications, length of stay, and cardiovascular risk factors, as well as improved quality of life. Cost-effectiveness will be evaluated.

Safety and Feasibility of Transcatheter Aortic Valve Replacement in COVID-19 Patients: A Case Series

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has led to a decrease in interventional treatment for structural heart disease worldwide. In this context, the management of patients with symptomatic severe aortic stenosis (AS) or bioprosthetic valve dysfunction (BVD) represents a clinical challenge, as a delay in aortic valve replacement procedures may increase short-term morbidity and mortality. We report four cases of TAVR performed in patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. All of them were discharged in good clinical conditions and no adverse events were reported at 30 days follow-up. Our experience suggests that in selected patients with mild SARS-CoV-2 infection and symptomatic native AS or BVD, TAVR has a favorable short-term outcome.

Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS)

The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD.

Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.

Consequences of canceling elective invasive cardiac procedures during Covid-19 outbreak

BACKGROUND

During COVID-19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming.

OBJECTIVE

The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID-19 outbreak in Spain.

METHODS

The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID-19 pandemic. These patients were followed-up until April 31th.

RESULTS

Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year-old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p-values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality.

CONCLUSION

Mortality at 45 days during COVID-19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.

Increasing Wait-Time Mortality for Severe Aortic Stenosis: A Population-Level Study of the Transition in Practice From Surgical Aortic Valve Replacement to Transcatheter Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has emerged as a reasonable alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis (AS). There is limited data on temporal trends in wait-times and access to care for patients with AS, irrespective of treatment modality. We sought to investigate the trends in wait-times for the treatment (either SAVR or TAVR) of AS in Ontario, Canada, and to understand the drivers of wait-list mortality and hospitalization due to heart failure.

METHODS

In this population-level retrospective cohort study, we identified patients from April 1, 2012, to March 31, 2018, who were referred for treatment of symptomatic severe AS awaiting either SAVR or TAVR. The primary outcome was the median total wait-time from referral date to either SAVR or TAVR procedure. Primary clinical outcomes were all-cause mortality and heart failure-related hospitalizations while on the wait-list.

RESULTS

The referral cohort consisted of a total of 22 876 referrals for aortic valve replacement, with (N=8098) TAVR and (N=14 778) SAVR referrals. The mean and median wait times for the overall AVR cohort were 87 and 59 days, respectively. The TAVR subcohort had longer wait-times (median 84 days) compared with the SAVR subcohort (median 50 days). Year over year, there was a statistically significant an increase in wait-times (P<0.001) for the overall AS cohort as well as each of the TAVR (P<0.0001) and SAVR (P<0.0001) subgroups. Wait-time mortality was 2.5% (TAVR 5.2% and SAVR 1.05%), while the cumulative probability of heart failure hospitalization was 3.6% (TAVR 7.7% and SAVR 1.3%).

CONCLUSIONS

In patients with severe symptomatic AS awaiting aortic valve replacement, there has been a trend of increasing wait times for both SAVR and TAVR. This was associated with increasing mortality and hospitalizations related to heart failure while on the wait-list.

Balloon aortic valvuloplasty for urgent treatment of severe aortic stenosis during coronavirus disease 2019 pandemic: a case report

An 86‐year‐old man affected by severe aortic stenosis (AS) was referred to our institution owing to decompensated heart failure. Three months before, the patient was scheduled for transcatheter aortic valve implantation (TAVI), which was postponed owing to the coronavirus disease 2019 (COVID‐19) outbreak. Owing to COVID‐19 suspicion, he underwent nasopharyngeal swab and was temporarily isolated. However, the rapid deterioration of clinical and haemodynamic conditions prompted us to perform balloon aortic valvuloplasty (BAV) as bridge to TAVI. The patient's haemodynamics improved; and the next day, the reverse transcriptase–polymerase chain reaction for COVID‐19 was negative. At Day 5, he underwent TAVI procedure. Subsequent clinical course was uneventful. During COVID‐19 pandemic, the deferral of TAVI procedure should be assessed on a case‐by‐case basis to avoid delay in patients at high risk for adverse events. BAV may be an option when TAVI is temporarily contraindicated such as in AS patients suspected for COVID‐19.

Ambulatory TAVR: Early Feasibility Experience During the COVID-19 Pandemic

The COVID-19 pandemic has modified practice for patients with symptomatic aortic stenosis and could result in higher mortality rates due to treatment delays. In this clinical case series, 3 patients underwent ambulatory transcatheter aortic valve replacement (TAVR) thanks to patient and entourage willingness, careful patient selection (including a history of permanent pacemaker placement), and a minimalist procedural approach. No complications occurred during the 30-day follow-up. Performing ambulatory TAVR could reduce the clinical consequences of wait times, minimize exposure to coronavirus contamination, and reduce the use of hospital resources that might be needed for COVID-19 patients. Thanks to a scrupulous minimalist TAVR protocol, ambulatory outpatient management of aortic stenosis was possible in the context of the COVID-19 pandemic.

Transcatheter aortic valve implantation during the COVID-19 pandemic: Clinical expert opinion and consensus statement for Asia

OBJECTIVES

The impact of the COVID-19 pandemic on the treatment of patient with aortic valve stenosis is unknown and there is uncertainty on the optimal strategies in managing these patients.

METHODS

This study is supported and endorsed by the Asia Pacific Society of Interventional Cardiology. Due to the inability to have face to face discussions during the pandemic, an online survey was performed by inviting key opinion leaders (cardiac surgeon/interventional cardiologist/echocardiologist) in the field of transcatheter aortic valve implantation (TAVI) in Asia to participate. The answers to a series of questions pertaining to the impact of COVID-19 on TAVI were collected and analyzed. These led subsequently to an expert consensus recommendation on the conduct of TAVI during the pandemic.

RESULTS

The COVID-19 pandemic had resulted in a 25% (10-80) reduction of case volume and 53% of operators required triaging to manage their patients with severe aortic stenosis. The two most important parameters used to triage were symptoms and valve area. Periprocedural changes included the introduction of teleconsultation, preprocedure COVID-19 testing, optimization of protests, and catheterization laboratory set up. In addition, length of stay was reduced from a mean of 4.4 to 4 days.

CONCLUSION

The COVID-19 pandemic has impacted on the delivery of TAVI services to patients in Asia. This expert recommendation on best practices may be a useful guide to help TAVI teams during this period until a COVID-19 vaccine becomes widely available.

Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the COVID-19 Pandemic: An ACC/SCAI Position Statement

The coronavirus disease-2019 (COVID-19) pandemic has strained health care resources around the world, causing many institutions to curtail or stop elective procedures. This has resulted in an inability to care for patients with valvular and structural heart disease in a timely fashion, potentially placing these patients at increased risk for adverse cardiovascular complications, including CHF and death. The effective triage of these patients has become challenging in the current environment as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID-19 pandemic against the risk of delaying a needed procedure. In this document, the authors suggest guidelines for how to triage patients in need of structural heart disease interventions and provide a framework for how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, the authors address the triage of patients in need of transcatheter aortic valve replacement and percutaneous mitral valve repair. The authors also address procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic.

Triage considerations for patients referred for structural heart disease intervention during the COVID-19 pandemic: An ACC/SCAI position statement

The coronavirus disease-2019 (COVID-19) pandemic has strained health care resources around the world, causing many institutions to curtail or stop elective procedures. This has resulted in an inability to care for patients with valvular and structural heart disease in a timely fashion, potentially placing these patients at increased risk for adverse cardiovascular complications, including CHF and death. The effective triage of these patients has become challenging in the current environment, as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID-19 pandemic against the risk of delaying a needed procedure. In this document, the authors suggest guidelines for how to triage patients in need of structural heart disease interventions and provide a framework for how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, the authors address the triage of patients in need of transcatheter aortic valve replacement and percutaneous mitral valve repair. The authors also address procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic.

Facilitating transcatheter aortic valve implantation in the era of COVID-19: Recommendations for programmes

The COVID-19 pandemic continues to significantly impact the treatment of people living with aortic stenosis, and access to transcatheter aortic valve implantation. Transcatheter aortic valve implantation (TAVI) programmes require unique coordinated processes that are currently experiencing multiple disruptions and are guided by rapidly evolving protocols. We present a series of recommendations for TAVI programmes to adapt to the new demands, based on recent evidence and the international expertise of nurse leaders and collaborators in this field. Although recommended in most guidelines, the uptake of the role of the TAVI programme nurse is uneven across international regions. COVID-19 is further highlighting why a nurse-led central point of coordination and communication is a vital asset for patients and programmes. We propose an alternative streamlined evaluation pathway to minimize patients' pre-procedure exposure to the hospital environment while ensuring appropriate treatment decision and shared decision-making. The competing demands created by COVID-19 require vigilant wait list management, with risk stratification, telephone surveillance and optimized triage and prioritization. A minimalist approach with close scrutiny of all parts of the procedure has become an imperative to avoid any complications and ensure patients' accelerated recovery. Lastly, we outline a nurse-led protocol of rapid mobilization and reconditioning as an effective strategy to facilitate safe next-day discharge home. As the pandemic abates, TAVI programmes must facilitate access to care without compromising patient safety, enable hospitals to manage the competing demands created by COVID-19 and establish new processes to support patients living with valvular heart disease.

Managing Severe Aortic Stenosis in the COVID-19 Era

The novel coronavirus disease-2019 (COVID-19) pandemic has created uncertainty in the management of patients with severe aortic stenosis. This population experiences high mortality from delays in treatment of valve disease but is largely overlapping with the population of highest mortality from COVID-19. The authors present strategies for managing patients with severe aortic stenosis in the COVID-19 era. The authors suggest transitions to virtual assessments and consultation, careful pruning and planning of necessary testing, and fewer and shorter hospital admissions. These strategies center on minimizing patient exposure to COVID-19 and expenditure of human and health care resources without significant sacrifice to patient outcomes during this public health emergency. Areas of innovation to improve care during this time include increased use of wearable and remote devices to assess patient performance and vital signs, devices for facile cardiac assessment, and widespread use of clinical protocols for expedient discharge with virtual physical therapy and cardiac rehabilitation options.