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Health care delivery, economics and global health care
Original research article
Multidisciplinary transcatheter aortic valve replacement heart team programme improves mortality in aortic stenosis
  1. Dylan R Jones1,2,
  2. Derek P Chew1,2,
  3. Matthew J Horsfall1,
  4. Anthony Ming-Yu Chuang1,2,
  5. Ajay R Sinhal1,
  6. Majo X Joseph1,
  7. Robert A Baker3,
  8. Jayme S Bennetts2,3,
  9. Joseph B Selvanayagam1,2 and
  10. Sam J Lehman1,2
  1. 1Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia
  2. 2Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
  3. 3Cardiac and Thoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
  1. Correspondence to Dr Dylan R Jones; dylanrjones{at}gmail.com

Abstract

Objectives To analyse the effect of the implementation of a transcatheter aortic valve replacement (TAVR) and multidisciplinary heart team programme on mortality in severe aortic stenosis (AS).

Methods A retrospective, observational cohort study was performed using the echocardiography, cardiothoracic surgery and TAVR databases between 1 January 2006 and 31 December 2016. Outcomes were compared between the pre- and post-TAVR programme eras in a tertiary referral centre providing transcatheter and surgical interventions for AS.

All-cause mortality within 5 years from diagnosis was determined for 3399 patients with echocardiographically defined severe AS.

Results Of 3399 patients, there were 210 deaths (6.2%) at 30 days and 1614 deaths (47.5%) at 5 years.

Overall, patients diagnosed in the post-TAVR programme era were older, with a lower ejection fraction and more severe AS, but were less comorbid.

Among 705 patients undergoing intervention, those in the post-TAVR programme era were older, with a lower ejection fraction and more severe AS but no significant differences in comorbidities.

Using an inverse probability weighted cohort and a Cox proportional hazards model, a significant mortality benefit was noted between eras alone (HR=0.86, 95% CI 0.77 to 0.97, p=0.015). When matching for age, comorbidities and valve severity, this benefit was more evident (HR=0.82, 95% CI 0.73 to 0.92, p=0.001).

After adjusting for the presence of aortic valve intervention, a significant benefit persisted (HR=0.84, 95% CI 0.75 to 0.95, p=0.005).

Conclusion The implementation of a TAVR programme is associated with a mortality benefit in the population with severe AS, independent of the expansion of access to intervention.

  • aortic stenosis
  • multidisciplinary communication
  • transcatheter aortic valve replacement
  • surgical aortic valve replacement
  • cardiovascular outcomes

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/openhrt-2018-000983

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    Footnotes

    • Contributors DRJ is the primary author and researcher for the manuscript. DPC, SJL, JSB and JB are PhD co-supervisors and contributed to the review and accuracy of the manuscript. DPC, assisted by AM-YC assisted with the statistical analysis. MJH is the data manager responsible for the extraction and linkage of the various databases. ARS, MXJ and RAB are the custodians for the TAVR, echocardiography and Cardiothoracic Suregery Unit (CTSU) databases, respectively. All coauthors reviewed the final manuscript and approved submission.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests DRJ received a Flinders University Research Scholarship to assist with his PhD studies.

    • Patient consent for publication Not required.

    • Ethics approval The Human Research Ethics Committee of the South Australian Department of Health approved this study (approval number: HREC/17/SAC/79).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No additional data are available.