Extended Statement by the British Cardiovascular Intervention Society President Regarding Transcatheter Aortic Valve Implantation

Abstract

Transcatheter aortic valve implantation (TAVI) has now become the default intervention for severe, symptomatic aortic stenosis (AS) in inoperable and high-risk patients and patients at intermediate risk who are anatomically suitable for the transfemoral approach, under the guidance of a multidisciplinary heart team. Evidence is building for the use of TAVI in low-risk patients and as a result, the number of TAVI procedures in all developed nations is increasing dramatically. The number of TAVI procedures exceeded the number of isolated surgical aortic valve replacements in the US in 2015 and all surgical aortic valve replacements in 2018 according to the latest Transcatheter Valve Therapy Registry data. 1 Although the UK is lagging behind most of these nations, the numbers of TAVI procedures is nevertheless increasing year by year.The British Cardiovascular Intervention Society (BCIS) has issued guidance as to how patients with AS should be managed and a service specification as to how TAVI should be performed. 2 We hope this will go some way to standardising care across the UK for patients with AS but we are aware that much more needs to be done. BCIS is collaborating with the Valve for Life campaign to analyse inequities in TAVI provision in the UK and we hope to work with NHS commissioners to address this, and to encourage new centres to provide TAVI where local provision is inadequate or impossible with current facilities. The following document forms the basis of what will be a prolonged effort to improve TAVI provision in the UK and standardise its delivery.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients with severe aortic stenosis: a systematic review and meta-analysis

“…In the pretranscatheter aortic valve implantation (TAVI) era, patients with severe degenerative symptomatic aortic stenosis (SAS) at high surgical risk had limited access to treatment options, as surgical aortic valve replacement (SAVR) was considered to have an unacceptably elevated risk of complications or death. 1 TAVI was developed as a lower impact, minimally invasive surgical alternative to provide such patients with a much-needed therapeutic option to ameliorate disease symptoms and improve quality of life. TAVI is now being more widely discussed as a useful option for patients at intermediate or even lower levels of surgical risk.…”

Aortic stenosis

“…Arrange cardiovascular assessment within six weeks for all patients who report exertional symptoms (dyspnoea or chest pain) and have an audible cardiac murmur,252627 and for patients with exertional symptoms but seemingly only moderate aortic stenosis according to a transthoracic echocardiogram28…”

Trends in Transcatheter Aortic Valve Implantation in Australia

“…[ 12 ] In comparison, current TAVI procedural rates for symptomatic severe AS have reached over 200 per million in many European countries, while in the US the number of TAVI procedures exceeded the number of all SAVR procedures in 2019, according to the latest transcatheter valve therapy registry data. [ 14 ]…”

“…The mandated requirement for heart team discussion is now the cornerstone of TAVI clinical practice in Australia and is entirely consistent with recommendations in Europe, North America and the UK. [ 14 ] It is anticipated that the role of the heart team will become particularly important with expansion of indications to lower risk groups. Heart team discussion is thought to minimise bias in patient selection, prevent indication creep and ultimately ensure optimal patient outcomes.…”

“…However this needs to be balanced with recommendations that TAVI should take place in major tertiary centres with on-site cardiac surgery, interventional radiology and intensive treatment units to appropriately manage complications as well as extensive operator and site experience, which has been shown to be an important predictor of patient outcomes. [ 14 , 16 ]…”