Introduction The treatment of high risk patients with severe aortic stenosis (AS) has been transformed by the availability of transcatheter aortic valve implantation (TAVI) alongside conventional high risk aortic valve replacement (AVR). Selection of patients for this procedure is clinically challenging and best achieved using a dedicated and experienced multidisciplinary team (MDT). A TAVI programme was established at our institution in September 2008 and the MDT from the outset comprised two interventional cardiologists, an imaging specialist, two cardiac surgeons, cardiac anaesthetist, general cardiologist and a nurse specialist. We report the MDT decision and outcome of 135 patients referred over the subsequent 15 months and the implication on service provision for all aspects of the management of AS.
Methods Clinical details of all patients referred to the high-risk aortic stenosis MDT were recorded and analysed prospectively. Outcome data were derived from the hospital database.
Results One thirty five patients (mean age 82 years, 50% male) were referred to the high-risk AS MDT (51% local cardiologists, 4% local surgeons, 34% DGH, 11% out of region). Many patients were referred with sufficient data to allow decision making and 45 underwent detailed assessment prior to consideration of TAVI (either following an index inpatient event or during elective admission).
To date, 29 of the 135 referred (20%, mean logistic Euroscore 20%) have undergone TAVI (nine apical and 20 femoral) with one (3.4%) procedural mortality, 30-day survival rate 90% and post-TAVI permanent pacemaker requirement 31%.
Ten patients (mean logistic Euroscore 22%) were unsuitable for TAVI but appropriate for palliative balloon valvuloplasty either due to significant left ventricular impairment or the presence of co-existent disease with impact on life expectancy. This procedure was undertaken with no in-hospital mortality, a mean reduction in trans-valvular gradient of 25% and a 30-day mortality of 5%.
Thirteen patients (mean logistic Euroscore 17.6%) have been referred for high risk AVR. There was one death (8%) 47 days post-AVR.
Continued medical therapy was recommended in 27 patients (20 excessive risk or unsuitable for TAVI or valvuloplasty, seven non-severe AS or alternative irreversible aetiology for symptoms eg, pulmonary disease).
Overall 12-month mortality for the entire cohort was 20%, highest mortality being seen in those patients deemed too high risk for any form of intervention (41%). Two patients died of AS while the TAVI programme was being conceived.
Conclusion Many patients with severe AS previously felt to be at excess risk for any intervention may be suitable for TAVI, surgical AVR or balloon valvuloplasty. Careful patient selection undertaken by a specialist MDT leads to excellent survival outcomes even in this high-risk patient population. The introduction of TAVI has increased surgical referral for AVR and re-introduced balloon valvuloplasty as a successful method of treatment.
- Aortic stenosis
- transcatheter aortic valve replacement