Transcatheter aortic valve implantation (TAVI): risky and costly

Brabandt, Hans Van; Neyt, Mattias; Hulstaert, Frank

doi:10.1136/bmj.e4710

Cited by 65 publications

(45 citation statements)

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“…Mean logistic EuroSCORE-I was 23. 4 3.1% and was above 20% in all studies, except for one (19 13%). 21 In those studies (n ¼ 5) in which reporting results was exclusively done using the Society of Thoracic Surgery score, 22,25,28,32,35 the mean risk of perioperative mortality was >5%.…”

Section: Resultsmentioning

confidence: 73%

Meta-Analysis of Predictors of All-Cause Mortality After Transcatheter Aortic Valve Implantation

Giordana

D’Ascenzo

Nijhoff

et al. 2014

The American Journal of Cardiology

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Section: Resultsmentioning

confidence: 73%

Meta-Analysis of Predictors of All-Cause Mortality After Transcatheter Aortic Valve Implantation

Giordana

D’Ascenzo

Nijhoff

et al. 2014

The American Journal of Cardiology

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“…These early successes led to a number of trials, such as the PARTNER and US Pivotal trials, which compared TAVI, SAVR and standard treatment outcomes ( Figure 1). As a result, TAVI is increasingly being considered as a less-invasive option for treatment of AS in younger and lower surgical risk patients, where SAVR is not necessarily contraindicated (6,7), although this is not without controversy (8).…”

Section: Introductionmentioning

confidence: 99%

Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond

Chakos

Wilson-Smith

Arora

et al. 2017

Ann. Cardiothorac. Surg.

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Background: Transcatheter aortic valve implantation/replacement (TAVI/TAVR) is becoming more frequently used to treat aortic stenosis (AS), with increasing push for the procedure in lower risk patients.Numerous randomized controlled trials have demonstrated that TAVI offers a suitable alternative to the current gold standard of surgical aortic valve replacement (SAVR) in terms of short-term outcomes. The present review evaluates long-term outcomes following TAVI procedures.Methods: Literature search using three electronic databases was performed up to June 2017. Studies which included 20 or more patients undergoing TAVI procedures, either as a stand-alone or concomitant procedure and with a follow-up of at least 5 years, were included in the present review. Literature search and data extraction were performed by two independent researchers. Digitized survival data were extracted from Kaplan-Meier curves in order to re-create the original patient data using an iterative algorithm and subsequently aggregated for analysis.Results: Thirty-one studies were included in the present analysis, with a total of 13,857 patients. Two studies were national registries, eight were multi-institutional collaborations and the remainder were institutional series. Overall, 45.7% of patients were male, with mean age of 81.5±7.0 years. Where reported, the mean Logistic EuroSCORE (LES) was 22.1±13.7 and the mean Society of Thoracic Surgeons (STS) score was 9.2±6.6. The pooled analysis found 30-day mortality, cerebrovascular accidents, acute kidney injury (AKI) and requirement for permanent pacemaker (PPM) implantation to be 8.4%, 2.8%, 14.4%, and 13.4%, respectively. Aggregated survival at 1-, 2-, 3-, 5-and 7-year were 83%, 75%, 65%, 48% and 28%, respectively. Conclusions:The present systematic review identified acceptable long-term survival results for TAVI procedures in an elderly population. Extended follow-up is required to assess long-term outcomes following TAVI, particularly before its application is extended into wider population groups. Ann Cardiothorac Surg 2017;6(5):432-443 www.annalscts.com IntroductionAs Western populations age, the prevalence of aortic stenosis (AS) is gradually increasing (1). In a select population, surgical aortic valve replacement (SAVR) is precluded by patient frailty and other comorbidities (2). The availability of transcatheter aortic valve implantation/ replacement (TAVI/TAVR), pioneered in the early 2000s, has made a significant impact on survival for these patients (3-5). These early successes led to a number of trials, such as the PARTNER and US Pivotal trials, which compared TAVI, SAVR and standard treatment outcomes ( Figure 1). As a result, TAVI is increasingly being considered as a less-invasive option for treatment of AS in younger and lower surgical risk patients, where SAVR is not necessarily contraindicated (6,7), although this is not without controversy (8).While the short-term outcomes of TAVI have been well explored, limited studies have examined longer term results (9,10). Additiona...

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“…37 Another problem is 'indication creep', whereby proof-of-benefit in selected patient groups is extrapolated uncritically to a wider spectrum of patients. Overseas studies suggest many implantations of costly devices, such as cardioverter-defibrillators, 38 resynchronisation pacemakers 39 and transcatheter aortic valves, 40 involve unproven indications. Both scenarios can lead to harm being done to some patients and resources being wasted.…”

Section: Defer the Use Of Unproven Interventionsmentioning

confidence: 99%

Ten clinician-driven strategies for maximising value of Australian health care

Scott¹

2014

Aust. Health Review

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Objective. To articulate the concept of high-value care (i.e. clinically relevant, patient-important benefit at lowest possible cost) and suggest strategies by which clinicians can promote such care in rendering the Australian healthcare system more affordable and sustainable.Methods. Strategies were developed by the author based on personal experience in clinical practice, evidence-based medicine and quality improvement. Relevant literature was reviewed in retrieving studies supporting each strategy.Results. Ten strategies were developed: (1) minimise errors in diagnosis; (2) discontinue low-or no-value practices that provide little benefit or cause harm; (3) defer the use of unproven interventions; (4) select care options according to comparative cost-effectiveness; (5) target clinical interventions to those who derive greatest benefit; (6) adopt a more conservative approach nearing the end of life; (7) actively involve patients in shared decision making and self-management; (8) minimise day-to-day operational waste; (9) convert healthcare institutions into rapidly learning organisations; and (10) advocate for integrated patient care across all clinical settings.Conclusions. Clinicians and their professional organisations, in partnership with managers, can implement strategies capable of maximising value and sustainability of health care in Australia.What is known about this topic? Value-based care has emerged as a unitary concept that integrates quality and cost, and is being increasingly used to inform healthcare policy making and reform. What does this paper add? There is scant literature that translates the concept of high value care into actionable enhancement strategies for clinicians in everyday practice settings. This article provides 10 strategies with supporting studies in an attempt to fill this gap. What are the implications for practitioners? If all practitioners, in partnership with healthcare managers, attempted to enact all 10 strategies in their workplaces, a significant quantum of healthcare resources could be redirected from low-to highvalue care, culminating in much greater health benefit from the healthcare dollars currently being spent. However, such reforms will require a shift in clinician thinking and practice away from volume-based care to value-based care.

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Transcatheter aortic valve implantation (TAVI): risky and costly

Abstract: Many of the 40 000 transcatheter procedures so far carried out cannot be justified on medical or cost effectiveness grounds. Hans Van Brabandt, Mattias Neyt, and Frank Hulstaert examine why practice has gone beyond the evidence

Cited by 65 publications

References 10 publications

Meta-Analysis of Predictors of All-Cause Mortality After Transcatheter Aortic Valve Implantation

Meta-Analysis of Predictors of All-Cause Mortality After Transcatheter Aortic Valve Implantation

Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond

Ten clinician-driven strategies for maximising value of Australian health care

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