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Canadian Journal of Cardiology

REAL-WORLD DATA OVER TIME FOR TRANSCATHETER AND SURGICAL AORTIC VALVE INTERVENTIONS IN QUÉBEC

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      BACKGROUND

      The Institut national d'excellence en santé et en services sociaux (INESSS) has collaborated with Québec's transcatheter aortic valve implantation (TAVI) programs since 2013 to evaluate processes of care and outcomes. In 2018-2019, data were also collected on surgical aortic valve replacement (SAVR). Herein, we describe real-world volume and outcome trends for these two patient groups, as well as processes of care and clinical characteristics over a 6-month period.

      METHODS AND RESULTS

      Volume and mortality have been ascertained for TAVI since 2013 in collaboration with all Québec programs, and from the Canadian Institute for Health Information (CIHI) for SAVR. From October 1, 2018 to March 31, 2019, patient characteristics and process of care data were also collected, in collaboration with clinical teams, for all TAVI and SAVR performed in patients aged ≥ 75 years. Rates of TAVI doubled between 2013-2014 and 2018-2019 (9.4 to 19.6 / 100,000 population), whereas rates of isolated SAVR (iSAVR) remained stable (19.8 to 21.5 / 100,000 population). Thirty-day mortality post-TAVI decreased from 4.8% in 2013-2016 to 2.4% in 2016-2019 amongst patients ≥ 75 years, and from 3.7% to 2.3% in younger patients. For iSAVR, 30-day mortality during the same periods decreased in patients ≥ 75 years, from 3.2% to 1.0%, but remained stable (at 1.0%) in younger patients. During the 6-month 2018-2019 period, 300 TAVI and 129 iSAVR in patients ≥ 75 years were examined. TAVI patients had a higher median age than iSAVR (84 vs. 78) and more comorbidities. For TAVI, median delay from referral to treatment decision was 72 days (inter-quartile range, IQR: 11-138) and 28 days (IQR: 7-75) from decision to procedure; for iSAVR, these were 17 (IQR: 1-49) and 63 days (IQR: 16-109), respectively. Median length of hospital stay was 3 days (IQR: 1-5) for TAVI, and 7 days (IQR: 6-10) for iSAVR. Incidence of in-hospital stroke, new pacemaker and 30-day mortality was 3.3%, 17.7% and 2.3% for TAVI, respectively, and 1.6%, 6.2% and 0% for iSAVR.

      CONCLUSION

      From 2013-2019, use of TAVI increased and a decrease in overall 30-day mortality associated with treatment for severe and symptomatic aortic stenosis was observed. Amongst elderly patients in 2018-2019, TAVI and SAVR patients had different characteristics, evaluation processes and wait times. Broadening of TAVI to patients at low surgical risk raises organizational and long-term clinical issues and may favour a shift from procedure-focused to disease-centred evaluation processes.
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