Validation of a heart team performance for patients with severe aortic stenosis

The application of a Heart team approach is now well recognized in the care of higher risk patients with severe aortic stenosis. The rationale for this team approach is to provide the expertise of different professionals in order to improve patient selection, procedural planning and management of higher risk patients, thus improving post procedural outcomes. However, the heart team approach is not consistently validated and no systematic metrics exist to assess the performance of the heart team decisions to refer patients either to surgical aortic valve replacement (SAVR), transcatheter aortic valve implantation (TAVI) or medical treatment. This study assesses the performance of the Heart team at the University of Montreal Hospital Centres. All patients who were discussed by the heart team between 2009-2018 were included in this study (113 SAVR and 170 TAVI). Observed to predicted (O:E) ratios were generated for mortality and morbidities for patients who got referred to SAVR defined by the Society of Thoracic Surgeons. A ratio of 1.5 discriminated between a heart team bad (>1.5) versus good decision ( < 1.5). An O:E ratio for mortality for TAVI patients was also generated following the same criteria. However, because the morbidities after TAVI are not the same as SAVR according to STS, we then compared the TAVI pertinent morbidities ratio to the one from major TAVI trials. O:E ratio for SAVR mortality and morbidities were categorized according to the STS risk scores (low: < 3%, intermediate: 3-8%, high: >8%). TAVR patients wee all considered high-risk for surgery. The O:E ratios for mortality and morbidities for TAVI and SAVR are included in Table 1. The individual comorbidities for TAVI include: moderate to severe paravalvular leak: 1.54, atrial fibrillation: 0.18, major bleeding: 1.72, Stroke: 2.0, Acute renal insufficiency: 1.3, vascular complications: 0.81 and permanent pacemaker 1.13. The patients with the lower STS, who got referred to SAVR by the heart team had higher morbidities probably explained by older age of the patients. Those patients should have potentially be referred for TAVI instead. Validation of the heart team decisions is important in order to offer the safest treatment for all patients and to find determinants of poor outcomes.