Provincial system of care optimizes access and outcomes in patients undergoing transcatheter aortic valve implantation

The British Columbia (BC) Transcatheter Heart Valve (THV) Program is a centrally coordinated, evaluated, and funded system of care led by Cardiac Services BC (CSBC) in close collaboration with provincial cardiac sites. The BC THV Program aims to ensure equitable access to transcatheter aortic valve implantation (TAVI) and other THV procedures, support excellent outcomes, and facilitate the planning of health services. We describe a prospective observational cohort of 583 patients who underwent TAVI in BC between March 2012 and June 2014. High surgical risk patients with aortic stenosis for TAVI are referred to four hospitals. Referral volumes and wait times are monitored by CSBC. Heart Teams at each site manage processes of care from referral to follow-up, and risk-stratify patients according to planned TAVI procedure. Lower volume and more complex TAVI procedures, including non-transfemoral access and valve-in-valve implantation are concentrated at a single site. In-hospital and thirty-day outcomes are reported according to VARC-2 definitions. There were 1,158 referrals for eligibility assessment received. The median wait time from acceptance to procedure was 37 days (IQR 16,70); there were 16 deaths on the wait list and 42 deaths under assessment. The median age was 83 (IQR 78,87) and median STS score was 6% (IQR 4,8). Transfemoral (TF) access was performed in 499 (85.6%) cases. 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 was 3.1% (TF: 2.6%; Non-TF: 6.0%) and disabling stroke occurred in 1.7% (TF: 1.4%; Non-TF: 3.6%). Major vascular complications occurred in 2.2% of patients (TF: 2.2%; Non-TF: 2.4%). Median length of stay was 3 (IQR 3,6) days (TF: 3 IQR3,5; Non-TF: 7 IQR5,11), with 93% of patients (TF: 94.2%; Non-TF: 84.1%) discharged directly home. Mortality outcomes achieved in the BC TF TAVI program, were superior to the reports of national registries, including US Transcatheter Valve Therapies (TVT), German Aortic Valve Registry (GARY), French Transcatheter Aortic Valve Intervention (FRANCE 2), and UK TAVI Registry. Length of stay was among the lowest reported in a health service region, with most patients discharged home. This experience demonstrates the potential benefits of a provincial system of care for TAVI. On-going evaluation is needed to ensure quality of services, optimal resource utilization, and health services planning as transcatheter treatment options become increasingly available.