Target Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 16, No. 6Target Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBTarget Aortic Stenosis: A National Initiative to Improve Quality of Care and Outcomes for Patients With Aortic Stenosis Brian R. Lindman, Gregg C. Fonarow, Gary Myers, Heather M. Alger, Christine Rutan, Katie Troll, Angeline Aringo, Melanie Shahriary, Mariell Jessup, Suzanne V. Arnold, Pinak B. Shah, Wilson Y. Szeto, Clyde W. Yancy and Catherine M. Otto Brian R. LindmanBrian R. Lindman Correspondence to: Brian R. Lindman, MD, MSc, FACC, Structural Heart and Valve Center, Vanderbilt University Medical Center, 2525 W End Ave, Suite 300-A, Nashville, TN 37203. Email E-mail Address: [email protected] https://orcid.org/0000-0002-6879-5343 Cardiovascular Division, Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.). Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow https://orcid.org/0000-0002-3192-8093 Cardiovascular Division, UCLA Medical Center, Los Angeles, CA (G.C.F.). Search for more papers by this author , Gary MyersGary Myers American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Heather M. AlgerHeather M. Alger https://orcid.org/0000-0003-1795-9675 American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Christine RutanChristine Rutan https://orcid.org/0000-0002-5071-1607 American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Katie TrollKatie Troll American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Angeline AringoAngeline Aringo https://orcid.org/0000-0001-9729-409X American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Melanie ShahriaryMelanie Shahriary American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Mariell JessupMariell Jessup https://orcid.org/0000-0002-3010-0112 American Heart Association (G.M., H.M.A., C.R., K.T., A.A., M.S., M.J.). Search for more papers by this author , Suzanne V. ArnoldSuzanne V. Arnold https://orcid.org/0000-0003-3367-0302 St. Luke’s Mid America Heart Institute, University of Missouri-Kansas City (S.V.A.). Search for more papers by this author , Pinak B. ShahPinak B. Shah https://orcid.org/0000-0002-1642-7557 Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (P.B.S.). Search for more papers by this author , Wilson Y. SzetoWilson Y. Szeto Department of Cardiac Surgery, University of Pennsylvania, Philadelphia (W.Y.S.). Search for more papers by this author , Clyde W. YancyClyde W. Yancy https://orcid.org/0000-0001-7271-4166 Cardiovascular Division, Northwestern Medical Center, Chicago, IL (C.W.Y.). Search for more papers by this author and Catherine M. OttoCatherine M. Otto https://orcid.org/0000-0002-0527-9392 Cardiovascular Division, University of Washington Medical Center, Seattle (C.M.O.). Search for more papers by this author Originally published20 Jun 2023https://doi.org/10.1161/CIRCOUTCOMES.122.009712Circulation: Cardiovascular Quality and Outcomes. 2023;16This article is commented on by the following:More TAVRs or Targets in Aortic Stenosis? A Call for Targeted Data Tracking to Improve Our Care of Valvular Heart DiseaseSee Editorial by Tanguturi and HungTo date, assessment of quality of care and outcomes for patients with aortic stenosis (AS) has centered on procedural and postprocedural outcomes as tracked by the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry and Society of Thoracic Surgeons surgical Adult Cardiac Surgery Database. However, there is evidence that symptomatic patients with severe AS are undertreated with aortic valve replacement (AVR), and lack of AVR in such patients is associated with a substantial adverse impact on symptoms, hospitalization, and survival.1,2 Although assessment of the quality of procedural and postprocedural care is important, this method does not quantify care gaps in patients who were not appropriately diagnosed and referred for initial treatment. These care gaps are especially important as more observations address the potential health care disparities as a function of race/ethnicity noted in the use of transcatheter aortic valve replacement. Ideally, quality measurement and improvement efforts should start upstream of AVR, include accurate diagnosis and assessment of disease severity, and capture timely referral and treatment with measures occurring throughout the continuum of care.3Goals and Vision of the ProgramThe goal of this initiative is to identify, measure, and report on processes that occur from the initial echocardiographic diagnosis of AS, with the long-term goal of improving patient outcomes.Local Challenges in ImplementationWith no existing mechanisms in place to measure the quality of care during the period between diagnosis of AS and treatment of AS, several challenges were encountered in the development of this initiative. Program metrics needed to be identified, redefined, clarified, and prioritized over time with feedback from participating sites. Sites were not accustomed to identifying and tracking patients along the patient journey from the point of detection/diagnosis to treatment, which required development and evolution of manual and semiautomated ways to identify and abstract data on these patients during the pilot period. Often, when patients were referred to tertiary centers for treatment, prior echocardiography reports and imaging studies were not available to complete case report forms (CRFs).Initiative to Improve Diagnosis and Treatment of ASDesignA scientific advisory group was formed by the American Heart Association to provide oversight and direction for the initiative. Members identified and defined metrics to characterize quality of management of patients with AS. To provide a broadly representative pilot experience, 15 hospitals were identified, which were diverse in geography, size, teaching status, and other characteristics (Figure S1). We included patients who had at least 1 care encounter (eg, clinic visit, echocardiogram) during or after 2020 in the analysis; sites were instructed to look back up to 24 months before January 1, 2020, for the latest echocardiogram performed during that time period. Sites queried their echocardiography database during a defined time frame and were asked to identify patients with moderate or severe AS and enter data on a subset (according to sampling instructions provided) into an online data platform. A broad spectrum of patients was identified, including those without appropriate follow-up, those treated with transcatheter or surgical AVR, and those treated with medical therapy or palliative care. Sixty-eight data elements were abstracted and covered demographics, medical history, symptom status, echocardiographic measurements (resting and dobutamine), exercise stress test, treatment choice and rationale, and relevant dates. Multiple encounters for each patient could be recorded depending on data available before the index echocardiogram and the management strategy selected. Sites were instructed to enter a minimum of 1 echocardiogram report per patient. Institutional review board approval was waived and not required for this quality improvement initiative. The authors declare that all supporting data are available within the article and its Supplemental Material.ImplementationA learning collaborative of all 15 sites was established with quarterly calls. During these calls, sites and American Heart Association staff discussed questions and best practices for data collection and refinements needed to the CRFs, reviewed real-time data observations, and discussed challenges, obstacles, and opportunities for improvement. The scientific advisory group was engaged and responsive to input from the learning collaborative and modified metrics and CRFs as appropriate. Many sites were not accustomed to querying their echocardiography database and had to learn how that could be reliably and efficiently performed. Whether and when a multidisciplinary heart team evaluation occurred was sometimes difficult to ascertain due to the lack of an explicit process at many centers or confusion regarding which clinicians comprised the heart team. Many tertiary centers lacked access to historical reports and data on patients referred to them from outside their system. Given that sites did not have to enter data on all patients with AS in their institution nor enter data on every encounter or diagnostic test for patients entered into the registry, there was heterogeneity and selection bias for patients and data entered into the database. Related to this, it was unclear in many cases whether the absence of information in the database reflected an event not done versus not entered. For example, while sites were instructed midway through the pilot to enter all relevant echocardiograms, they were initially only required to enter 1 echocardiogram for a patient at the start of the baseline period of 2020. These realities influenced and limited evaluation of performance on the quality metrics of interest.OutcomeThis pilot initiative was focused on developing a process to evaluate quality in the management and timely treatment of patients with AS and gathering data on current state performance for proposed metrics at the sites. Data were collected from 15 sites on 6865 encounters and 2510 unique patients (42% women, 15% were non-White or Hispanic; Table S1). Severity of AS was based on the qualitative characterization on the echocardiogram CRF, which was based on the clinical echocardiography report. AS-related symptoms (ie, chest pain, breathlessness, syncope, or reduced activity level), were most frequently observed among those with severe AS but also present among half of those with moderate AS. Among 1286 patients with symptomatic severe AS, 596 (46%) were treated with transcatheter AVR, 223 (17%) were treated with surgery, and 467 (36%) did not undergo AVR.Metrics AssessmentThe Table includes the data for the metrics analyzed.Table. American Heart Association Target AS Pilot Initiative MetricsSiteAllABCDEFGHIJKLMNOTimely follow-up of surveillance echocardiograms* Moderate AS (qualitative categorization)95.9% (348/363)97.9%94.4%94.4%NA100.0%NA92.7%100.0%100.0%95.8%98.2%90.9%100.0%95.6%93.3% Moderate AS (AVA, 1.01–1.50 cm2)95.6% (216/226)100.0%90.5%94.9%NA100.0%NA88.9%100.0%100.0%100.0%100.0%100.0%NA93.3%87.5% Severe AS (qualitative categorization)92.6% (324/350)90.9%87.2%85.7%88.9%93.8%NA97.0%100.0%NA91.1%98.1%93.8%100.0%85.3%100.0% Severe AS (AVA ≤1.0 cm2)90.8% (463/510)87.9%88.6%78.8%83.3%100.0%NA96.3%100.0%100.0%92.5%95.1%91.2%100.0%86.7%88.2%Echo completeness AVA included93.9%92.0%98.0%100.0%87.6%91.6%94.9%92.2%95.8%97.4%89.1%98.9%98.1%100.0%94.8%93.7% Mean gradient included98.5%96.6%98.0%99.4%97.5%99.2%98.3%98.9%97.2%100.0%99.4%99.7%99.5%100.0%98.4%97.6% Peak gradient or peak velocity included98.4%99.2%98.0%99.2%95.9%98.1%94.9%97.1%96.5%100.0%99.9%98.2%100.0%94.2%98.6%97.6% LVEF included98.7%99.0%99.7%99.7%97.5%99.5%100.0%99.1%98.6%100.0%94.5%98.5%99.1%100.0%99.9%99.2% Qualitative AS severity categorization99.9%99.8%100.0%100.0%99.2%100.0%100.0%99.9%100.0%100.0%100.0%100.0%99.5%100.0%100.0%100.0% Echo reports with all 5 variables91.82%89.6%97.4%98.6%82.6%90.5%91.5%91.0%95.1%97.4%83.9%95.8%97.6%94.2%94.0%92.9%MDT evaluation and treatment of AS Symptomatic severe AS with MDT visit before or up to 60 d after diagnosis†68.4% (880/1286)70.9% (73/103)44.4% (32/72)64.6% (64/99)51.1% (24/47)57.3% (43/75)96.8% (30/31)80.5% (70/87)28.8% (19/66)100% (56/56)67.3% (74/110)77.4% (113/146)67.1% (57/85)46.3% (25/54)92.0% (195/212)11.6% (5/43) Symptomatic severe AS treated with TAVR/SAVR within 90 d of diagnosis†51.8% (666/1286)32.0% (33/103)40.3% (29/72)53.5% (53/99)68.1% (32/47)42.7% (32/75)100% (31/31)51.7% (45/87)59.1% (39/66)85.7% (48/56)30.0% (33/110)66.4% (97/146)8.2% (7/85)63.0% (34/54)63.7% (135/212)41.9% (18/43) Symptomatic severe AS seen by MDT who were treated with TAVR/SAVR within 30 d34.4% (281/816)2.5% (1/40)45.5% (15/33)51.5% (35/68)57.1% (12/21)27.3% (12/44)56.7% (17/30)25.0% (15/60)58.8% (10/17)37.5% (18/48)8.3% (8/96)52.7% (59/112)13.2% (7/53)36.0% (9/25)36.0% (59/164)80.0% (4/5) Any severity or symptom classification of AS treated with TAVR or SAVR who had MDT visit before treatment85.4% (908/1063)87.3% (89/102)87.3% (48/55)95.7% (67/70)55.6% (20/36)89.7% (35/39)75.0% (30/40)98.8% (82/83)33.3% (17/51)100.0% (63/63)93.1% (81/87)94.1% (127/135)95.0% (19/20)52.1% (25/48)99.0% (199/201)18.2% (6/33) Any severity or symptom classification of AS treated with SAVR who had MDT visit before treatment72.4% (210/290)72.2% (26/36)40.0% (4/10)75.0% (9/12)25.0% (4/16)83.3% (10/12)NA (0/0)100.0% (24/24)15.0% (3/20)NA (0/0)91.7% (33/36)77.8% (21/27)100.0% (4/4)12.5% (3/24)100.0% (69/69)NA (0/0) Any severity or symptom classification of AS treated with TAVR who had MDT visit before treatment90.3% (698/773)95.5% (63/66)97.8% (44/45)100.0% (58/58)80.0% (16/20)92.6% (25/27)75.0% (30/40)98.3% (58/59)45.2% (14/31)100.0% (63/63)94.1% (48/51)98.1% (106/108)93.8% (15/16)91.7% (22/24)98.5% (130/132)18.2% (6/33)AS indicates aortic stenosis; AVA, aortic valve area; LVEF, left ventricular ejection fraction; MDT, multidisciplinary team; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.* Timely follow-up of echocardiograms: moderate AS and severe AS were evaluated by both the qualitative description of AS severity given in the echocardiogram report and by the AVA. Timely follow-up was defined as a follow-up echocardiogram within 24+/-2 mo for moderate AS or 12+/-2 mo for severe AS.† Diagnosis date for symptomatic severe AS was the date at which both severe AS was detected by echocardiogram and AS-related symptoms were present.Echocardiographic Surveillance of ASAmong those with moderate AS (aortic valve area [AVA], 1.01–1.50 cm2) with a follow-up echocardiogram entered into the database, 95.6% of studies were completed within 24 months; among those with severe AS (AVA, ≤1.0 cm2) with a follow-up echocardiogram entered into the database, 90.8% of studies were completed within 12 months. Notably, however, since sites were not required to enter >1 echocardiogram for a patient, it could not be determined whether the apparent lack of a follow-up echocardiogram reflected that it was not done or simply was not entered by the site abstractor. Consequently, the analysis of the timeliness of surveillance echocardiograms was restricted to those with at least 2 echocardiograms entered into the database.Echocardiography Report CompletenessEchocardiography report completeness was determined by 5 essential measures that should be included in any echocardiography report generated for AS: AVA, transvalvular mean gradient, transvalvular peak gradient or peak velocity (Vpeak), left ventricular ejection fraction, and the qualitative AS severity categorization. Overall, 91.8% of the echocardiograms entered into the database had all 5 of these measures reported.Symptomatic Severe AS and Multidisciplinary Team VisitAmong 1286 patients with symptomatic severe AS, 880 (68.4%; site range, 11.6%–100%) had a multidisciplinary team (MDT) visit before or within 60 days after the diagnosis; an additional 97 (7.5%) had an MDT visit >60 days after diagnosis.Symptomatic Severe AS Treated With AVRApproximately half (51.8%, 666/1286; site range, 8.2%–100%) of the patients with symptomatic severe AS were treated with transcatheter or surgical AVR within 90 days after diagnosis; an additional 186 (14.5%) underwent AVR >90 days after diagnosis.Symptomatic Severe AS Seen by MDT and Treated With AVRAmong the 816 patients with symptomatic severe AS seen by the MDT on the day of diagnosis or after, 281 (34.4%; site range, 2.5%–80%) underwent AVR within 30 days of the MDT visit; an additional 286 (35.0%) underwent AVR >30 days after the MDT visit.AS Treated With Surgical or Transcatheter AVR Evaluated by the MDTAmong the 1063 patients with AS treated with AVR (regardless of severity or symptoms), 85.4% were evaluated by the MDT, but MDT evaluation was more common before transcatheter aortic valve replacement (90.3%) than surgical aortic valve replacement (72.4%) with substantial variation across sites. Notably, the manner with which information regarding MDT evaluation was ascertained may have yielded overestimates on the frequency of its occurrence.Originally Intended but Not EvaluatedWe intended to evaluate frequency of performing (1) a treadmill stress test among patients with asymptomatic severe high-gradient AS and (2) a dobutamine stress echocardiogram among patients with AVA ≤1.0 cm2 and a low-gradient and left ventricular ejection fraction <50%, but the instructions to sites and CRF structure prevented us from reliably determining these metrics. Because of the instructions given to sites for data entry for the pilot, the overall and site-specific data may be biased by how sites selected patients and data to enter into the database. Also, the ongoing COVID-19 pandemic likely influenced performance of several of the metrics assessed.Moving From This Pilot Initiative to a National ProgramSummary of the ExperienceBefore this pilot initiative, there were no systematic attempts to measure quality of care for patients with AS during the period from diagnosis to treatment. This initiative included a proposal of metrics to measure quality care and a process to ascertain data from a diverse group of sites. Leveraging an interactive learning collaborative and engagement of multiple stakeholders, throughout the pilot and as the next phase is anticipated, numerous refinements have been made to the quality metrics, CRF data elements, and instructions to sites for data entry and patient sampling in order to optimize future implementation.Translation to Other SettingsThis pilot project provided indispensable and iterative learning before deploying metrics and implementation of the initiative to more hospitals. Because diverse hospitals were selected for the pilot, translation of this initiative to a variety of hospitals should be eminently feasible. The CRF was streamlined to clarify the precise information required for completion. Specifically, once the AVA is <1.5 cm2, sites will be asked to enter all subsequent echocardiograms (resting or dobutamine), CT scans (for aortic valve calcium score), or treadmill stress tests; information from clinical encounters will likely only be entered once the AVA is ≤1.0 cm2 or Vpeak is ≥4 m/s. Characterization of AS severity will be made using the echocardiographic data entered (complemented by dobutamine stress echocardiogram or aortic valve calcium score). A key focus of scaling this quality improvement initiative will be maximizing the degree to which automated data abstraction can be used to reduce the burden on sites.Future Directions and ChallengesAs the pilot phase of this initiative comes to a close, the American Heart Association is poised to improve and expand this quality initiative from 15 pilot sites to 80 hospitals to gradually formalize a robust quality program for the management of patients with AS between diagnosis and treatment.Measuring QualityInformed by this pilot initiative, the anticipated primary quality metric is (1) among individuals with an AVA ≤1.0 cm2 or Vpeak ≥4.0 m/s on any echocardiogram, what percentage of patients who have a class I indication for AVR have been treated within 90 days of the echocardiogram.4 The key secondary metrics will include (1) the percentage of echocardiograms with AS that consistently report AVA, transvalvular mean gradient, transvalvular peak gradient (or Vpeak), stroke volume index, left ventricular ejection fraction, and a qualitative description of AS severity; (2) the percentage of echocardiograms showing moderate or severe AS that have a follow-up echocardiogram within 24 or 12 months, respectively; (3) the percentage of patients treated with surgical or transcatheter AVR who were seen by the heart valve MDT before the procedure; and (4) the percentage of patients with a class I indication for AVR who have been treated within 30 days of the MDT evaluation.Improving QualityWhile the pilot initiative initially focused on how to measure quality and refine data elements needed to characterize performance, an important future direction is to determine what system changes improve the quality of care and then disseminate those best practices to underperforming sites in order to optimize quality most broadly.Addressing Disparities in CareImportantly, this effort to measure quality and quantify site performance is anticipated to help address current disparities in the treatment of patients with AS based on sex, race, and ethnicity.5 However, specifically examining whether any improvements in quality are equally distributed across different subgroups of patients will be critical to the success of this initiative.ConclusionsThe Target AS pilot initiative lays the groundwork for ongoing refinement and broader implementation of a formalized program to more reliably measure performance on the quality of care from diagnosis of AS to treatment, which should provide a foundation for identifying and disseminating best practices to optimize quality in a manner that also improves equity in care.Article InformationSources of FundingEdwards Lifesciences provided funding to the American Heart Association to support the Target Aortic Stenosis initiative.Disclosures Dr Lindman is supported by R01AG073633 from the National Institutes of Health and has consulted for and received research grants from Edwards Lifesciences. Dr Fonarow reports consulting with Abbott, Amgen, AstraZeneca, Bayer, Cytokinetics, Eli Lilly, Edwards Lifesciences, Janssen, Medtronic, Merck, and Novartis. Dr Szeto has served on the advisory board and as an investigator and speaker for Edwards Lifesciences and Medtronic. Dr Alger is affiliated with Anumana, Inc, and is an employee of Nference, Inc; her contributions to the present work were completed as an employee of the American Heart Association. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 436.Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCOUTCOMES.122.009712.Circulation: Cardiovascular Quality and Outcomes is available at https://www.ahajournals.org/journal/circoutcomesCorrespondence to: Brian R. Lindman, MD, MSc, FACC, Structural Heart and Valve Center, Vanderbilt University Medical Center, 2525 W End Ave, Suite 300-A, Nashville, TN 37203. Email brian.r.lindman@vumc.orgReferences1. Li SX, Patel NK, Flannery LD, Selberg A, Kandanelly RR, Morrison FJ, Kim J, Tanguturi VK, Crousillat DR, Shaqdan AW, et al. Trends in utilization of aortic valve replacement for severe aortic stenosis.J Am Coll Cardiol. 2022; 79:864–877. doi: 10.1016/j.jacc.2021.11.060CrossrefMedlineGoogle Scholar2. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363:1597–1607. doi: 10.1056/NEJMoa1008232CrossrefMedlineGoogle Scholar3. Lindman BR, Lowenstern A. The alarm blares for undertreatment of aortic stenosis: how will we respond?J Am Coll Cardiol. 2022; 79:878–881. doi: 10.1016/j.jacc.2021.12.024CrossrefMedlineGoogle Scholar4. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines.Circulation. 2021; 143:e72–e227. 10.1161/CIR.0000000000000923LinkGoogle Scholar5. Batchelor W, Anwaruddin S, Ross L, Alli O, Young MN, Horne A, Cestoni A, Welt F, Mehran R. Aortic valve stenosis treatment disparities in the underserved: JACC council perspectives.J Am Coll Cardiol. 2019; 74:2313–2321. doi: 10.1016/j.jacc.2019.08.1035CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByTanguturi V and Hung J (2023) More TAVRs or Targets in Aortic Stenosis? A Call for Targeted Data Tracking to Improve Our Care of Valvular Heart Disease, Circulation: Cardiovascular Quality and Outcomes, 16:6, (e010073), Online publication date: 1-Jun-2023.Related articlesMore TAVRs or Targets in Aortic Stenosis? A Call for Targeted Data Tracking to Improve Our Care of Valvular Heart DiseaseVarsha K. Tanguturi, et al. Circulation: Cardiovascular Quality and Outcomes. 2023;16 June 2023Vol 16, Issue 6 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.122.009712PMID: 37339188 Originally publishedJune 20, 2023 Keywordsethnicityaortic valve stenosisaortic valve replacementpatient acuityechocardiographycardiologyquality of health carePDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationCardiovascular SurgeryEchocardiographyQuality and OutcomesValvular Heart Disease