A PROVINCIAL APPROACH TO THE DEVELOPMENT OF A TRANSCATHETER AORTIC VALVE IMPLANTATION PROGRAM: SUPPORTING PATIENT ACCESS AND QUALITY OF CARE

Transcatheter aortic valve implantation (TAVI) is rapidly emerging as the recommended or preferred therapy for many patients with severe aortic stenosis. The current shift in the management of valvular heart disease presents challenges for clinicians, administrators and policy-makers to support therapy development while ensuring adherence to indications, equitable and timely patient access and excellent outcomes. The British Columbia (BC) Transcatheter Heart Valve (THV) program was developed to support the implementation and evaluation of TAVI and other THV therapies within a comprehensive provincial program. Guided by the Canadian Cardiovascular Society Position Statement on TAVI (2012), the program aims to provide a standardized and outstanding program at multiple sites with similar evidence-based processes of care and excellent outcomes. Following the completion of a site readiness plan and support for early case selection, the Provincial THV Program developed TAVI sites at four cardiac centres in British Columbia. Regular reporting of referral volumes, treatment decision, and wait list status facilitated patient access planning. Case selection and outcomes were evaluated and reported according to the Valve Academic Research Consortium (VARC2) and provincial process indicators. In 2013, 652 referrals were made to the sites of the Provincial THV program and 252 (39%) patients had TAVI (transfemoral and non-transfemoral vascular access). Age was 82.4 ± 7 years; 151 patients (60 %) were men; mean STS predicted risk of mortality was 7 ± 4. Patient characteristics, and in-hospital and 30-day outcomes are outlined in Table 1. Median hospital stay was 3 days (IQR, 3-6 days), with 236 patients (96%) discharged home. At the time of 30-day follow-up, the 1.6% in-hospital mortality rate remained unchanged, and the hospital re-admission rate was 14%; 92% experienced NYHA Functional Class I or II symptoms, and the mean aortic valve area was 1.6 ± 0.4 cm2measured by transthoracic echocardiography. The mortality outcomes achieved in the BC TF TAVI program in 2013 were superior to the recently published US Transcatheter Valve Therapies (TVT) registry outcomes which reported 5.5% in-hospital and 7.6% 30-day mortality. The adherence to provincial indications and the excellence of outcomes attest to the collaborative efforts of the Heart Teams to ensure quality at all sites. This approach supports readiness for the evidence-based implementation of future transcatheter therapies.