Regional Systems of Care to Optimize Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

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• 作者：Dion Stub ; MBBS ; PhD^&lowast ; ; ^&dagger ; ; Sandra Lauck ; PhD^&lowast ; ; ^&Dagger ; ; ^§ ; ; May Lee ; MSc^‖ ; Min Gao ; MD ; PhD^‖ ; Karin Humphries ; DSc^&Dagger ; ; ^‖ ; Albert Chan ; MD^&Dagger ; ; ^¶ ; ; Anson Cheung ; MD^&lowast ; ; ^&Dagger ; ; Richard Cook ; MD^&lowast ; ; ^&Dagger ; ; ^# ; Anthony Della Siega ; MD^&lowast ; &lowast ; ; Jonathon Leipsic ; MD^&lowast ; ; ^&Dagger ; ; Jay Charania ; MD^¶ ; ; Danny Dvir ; MD^&lowast ; ; ^&Dagger ; ; Tim Latham ; MD^¶ ; ; Jopie Polderman ; BSN^§ ; ; Simon Robinson ; MBChB ; MD^&lowast ; &lowast ; ; Daniel Wong ; MD^¶ ; ; Christopher R. Thompson ; MD^&lowast ; ; ^&Dagger ; ; David Wood ; MD^&lowast ; ; ^&Dagger ; ; ^# ; Jian Ye ; MD^&lowast ; ; ^&Dagger ; ; John Webb ; MD^&lowast ; ; ^&Dagger ; ; ^§ ; ; ^{john.webb@vch.ca" class="auth_mail" title="E-mail the corresponding author}
• 关键词：aortic stenosis ; transcatheter aortic valve replacement
• 刊名：JACC: Cardiovascular Interventions
• 出版年：2015
• 出版时间：28 December 2015
• 年：2015
• 卷：8
• 期：15
• 页码：1944-1951
• 全文大小：329 K

文摘

This study sought to describe the development of a multicenter, transcatheter aortic valve replacement program and regional systems of care intended to optimize coordinated, efficient, and appropriate delivery of this new therapy.

Background

Transcatheter aortic valve replacement (TAVR) has become an accepted treatment option for patients with severe aortic stenosis who are at high surgical risk. 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 system of care for patients undergoing TAVR in British Columbia, Canada.

Methods

We describe a prospective observational cohort of 583 patients who underwent TAVR in British Columbia between 2012 and 2014. Regionalization of TAVR care in British Columbia refers to a centrally coordinated, funded, and evaluated program led by a medical director and a multidisciplinary advisory group that oversees planning, access to care, and quality of outcomes at the 4 provincial sites. Risk-stratified case selection for transfemoral TAVR is performed by heart teams at each site on the basis of consensus provincial indications. Referrals for lower volume and more complicated TAVR, including nontransfemoral access and valve-in-valve procedures, are concentrated at a single site. In-hospital and 30-day outcomes are reported.

Results

The median age was 83 years (interquartile range [IQR]: 78 to 87 years) and median STS score was 6% (IQR: 4% to 8%). Transfemoral access was performed in 499 (85.6%) cases and nontransfemoral in 84 (14.4%). Transcatheter valve-in-valve procedures in for failed bioprosthetic valves were performed in 43 patients (7.4%). A balloon-expandable valve was inserted in 386 (66.2%) and a self-expanding valve in 189 (32.4%). All-cause 30-day mortality was 3.5%. All-cause in-hospital mortality and disabling stroke occurred in 3.1% and 1.9%, respectively. Median length of stay was 3 days (IQR: 3 to 6 days), with 92.8% of patients discharged directly home.

Conclusions

This experience demonstrates the potential benefits of a regional system of care for TAVR. Excellent outcomes were demonstrated: most patients had short in-hospital stays and were discharged directly home.