Patient Disposition and Clinical Outcome After Referral to a Dedicated TAVI Clinic

Miroslawa Gorecka; Catriona Reddin; Gillian Madders; Laura Monaghan; Antoinette Neylon; Faisal Sharif; Brian Hynes; Evelyn Fennelly; Fiachra McHugh; Niamh Martin; Khalid Mohammed; Venu Reddy Bijjam; David Veerasingam; Alan Soo; Mark DaCosta; William Wijns; Darren Mylotte

doi:10.3389/fcvm.2019.00188

Patient Disposition and Clinical Outcome After Referral to a Dedicated TAVI Clinic

Front Cardiovasc Med. 2020 Jan 10:6:188. doi: 10.3389/fcvm.2019.00188. eCollection 2019.

Authors

Miroslawa Gorecka¹, Catriona Reddin¹, Gillian Madders¹, Laura Monaghan¹, Antoinette Neylon¹, Faisal Sharif^{1

2}, Brian Hynes¹, Evelyn Fennelly¹, Fiachra McHugh², Niamh Martin², Khalid Mohammed¹, Venu Reddy Bijjam¹, David Veerasingam³, Alan Soo³, Mark DaCosta³, William Wijns^{2

4}, Darren Mylotte^{1

2}

Affiliations

¹ Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland.
² School of Medicine, National University of Ireland, Galway, Ireland.
³ Department of Cardiothoracic Surgery, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland.
⁴ The Lambe Institute for Translational Medicine and Curam, SAOLTA University Healthcare Group, National University of Ireland Galway, Galway, Ireland.

Abstract

Introduction: Transcatheter aortic valve implantation (TAVI) is the standard of care for the majority of patients with severe symptomatic aortic stenosis (AS) at excessive-, high- and intermediate-surgical risk. A proportion of patients referred for TAVI do not undergo the procedure and proceed with an alternate treatment strategy. There is scarce data describing the final treatment allocation of such patients. Hence, we sought to evaluate the final treatment allocation of patients referred for TAVI in contemporary practice. Methods: We performed a single center prospective observational study, including all patients referred to our institution for treatment of severe aortic stenosis between February 2014 and August 2017. Baseline demographic and clinical data were recorded. Patients were categorized according to treatment allocation: TAVI, surgical aortic valve replacement (SAVR) or optimal medical therapy (OMT). Clinical outcomes were adjudicated according to VARC-2 definitions. All patients were discussed at a dedicated Heart Team meeting. Results: Total of 245 patients were referred for assessment to a dedicated TAVI clinic during the study period. Patients with moderate (N = 32; 13.1%) and asymptomatic (N = 31; 13.1%) AS were excluded. Subsequently, 53.9% (N = 132) received TAVI, 12.7% (N =31) were managed with OMT, and 7.3% (N =18) had SAVR. Reasons for OMT included primarily: patient's preference (N = 12; 38.7%); excessive surgical risk (N = 4; 12.9%) and severe frailty (N = 5; 16.1%). Reasons for surgical referral included low surgical risk (N = 11; 61.1%), excessive annulus size (N = 5; 27.8%), and aortic root dilatation (N = 2; 11.1%). Patients proceeding to SAVR had lower surgical risk than those in either the OMT or TAVI cohorts (P < 0.001). Mean STS score in SAVR group was 2.2 ± 1.3 vs. 4.5 ± 2.4 in OMT cohort and 6.1 ± 4.9 in TAVI cohort. Six-month all-cause mortality was 16.7, 19.4, and 9.3% among those receiving SAVR, OMT, and TAVI, respectively. Conclusions: Almost half of all patients with severe AS referred to a dedicated TAVI clinic did not receive a TAVI. A considerable proportion of patients were reclassified as moderate AS (13%), were asymptomatic (13%), or intervention was determined to be futile (13%) due to advanced frailty. Early detection and increased awareness of valvular heart disease are required to increase the number of patients that can benefit from TAVI.

Keywords: OMT; SAVR; TAVI; aortic stenosis; optimal medical therapy; patient disposition; surgical aortic valve replacement; transcatheter aortic valve implantation.