Introduction Transcatheter Aortic Valve Implantation (TAVI) is an established treatment option for severe aortic stenosis (AS), with over 5000 procedures performed in the UK in 2019. Given the high morbidity and mortality associated with delay to treatment, the British Cardiovascular Intervention Society proposes a diagnosis to procedure window of 18 weeks. However, in the UK TAVI Survey (2019), over 50% of centres reported difficulty in increasing capacity to meet this demand and the average timescale to TAVI was far longer than this target at 155 days. Streamlining patients to a dedicated structural clinic, a model proposed by Valve for Life UK, is therefore desirable to achieving these targets.
Methods To improve the timeline to TAVI at a district general hospital (DGH), we optimised the referral process in 3 key areas. Firstly, direct triage to TAVI clinic by physiologists at the time of echo diagnosis, negating the need for initial assessment by a general cardiologist. We utilised specialist CT analysis software (3-Mensia), allowed CT images to be analysed locally rather than during MDT meetings, increasing capacity to discuss more cases in the time saved. Lastly, the procedure was often completed by the same structural interventionalist that had initially assessed the patient, eliminating the need for further clinic review in a specialist centre and providing continuity of care. We compared 2 pathways of patient care: pathway 1, representing existing processes, and pathway 2, representing this novel way of working.Data was collected retrospectively over a 2-year period (pathway 1 duration 16 months, pathway 2 duration 7 months) for all patients with severe aortic stenosis who were intended for TAVI procedure. We considered death whilst waiting for procedure or admission with progressive AS symptoms as adverse events.
Results A total of 65 cases were reviewed, 44 were managed as outpatients and 15 inpatients. We excluded 5 cases treated along both pathways and 1 deemed clinically not suitable for TAVI after initial investigation. Of the 44 outpatients, 28 patients were managed in pathway 1 (1.8 patients per month) and 16 in pathway 2 (2.3 patients per month). The mean time from entry to pathway to procedure was 221 days in pathway 1 and 87 days in pathway 2 (p<0.001). 94% of outpatients in pathway 2 were treated within the 18-week target compared to only 19% in pathway 1. There were 5 adverse events in pathway 1 but no adverse events in pathway 2 (figure 1).
Conclusions Improving our local TAVI pathway has led to a significant reduction in the time to treatment. Most outpatients now undergo TAVI well within the BCIS 18-week target and 68 days faster than the UK average. Though the numbers are small, we also demonstrated an associated reduction in adverse events. These findings suggest that adopting a dedicated structural clinic model has led to significant improvements at DGH level, ultimately resulting in reducing the time to TAVI and improving patient care.
Conflict of Interest None
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