Regional systems of care to optimise outcomes in patients undergoing transcatheter aortic valve implantation (TAVI)

Background: TAVI has become an accepted treatment option for patients with high risk calcific aortic stenosis. Regional systems of care have led to improvements in outcomes for patients undergoing intervention for myocardial infarction, cardiac arrest, and stroke. We implemented a regional systems of care for patients undergoing TAVI in British Columbia (BC), Canada. Methods: We describe a prospective observational cohort of 583 patients who underwent TAVI in BC between 2012 and 2014. Regionalisation of care in BC, refers all high risk patients with aortic stenosis for TAVI to four hospitals. Heart Teams at each site risk stratify patients according to planned TAVI procedure, with more complicated TAVI patients including non-femoral access and Valve-in-Valve procedures concentrated at a single site. In-hospital and thirty-day outcomes are reported according to VARC-2 definitions. Results: The median age was 83 (IQR 78,87) and median STS score was 6%(IQR 4-8). Transfemoral access was performed in 499(85.6%) of cases and non-transfemoral in 84(14.4%). Transcatheter valve-in-valve procedure in patients with failed bioprosthetic valves was performed in 43(7.4%). A balloon expandable valve was inserted in 386(66.2%) and a self-expanding valve in 189(32.4%). All cause in-hospital mortality and disabling stroke occurred in 3.1% and 1.7% respectively. Major vascular complications occurred in 2.2% of patients. Median length of stay was 3(IQR 3,6) days, with 93% of patients discharged directly home. Conclusion: British Columbia demonstrates the potential benefits of a regional system of care to TAVI. Excellent outcomes were demonstrated, with most patients having short in-hospital stays and being discharged directly home.