Society Position Statement
2019 Canadian Cardiovascular Society Position Statement for Transcatheter Aortic Valve Implantation

https://doi.org/10.1016/j.cjca.2019.08.011Get rights and content

Abstract

Transcatheter aortic valve implantation (TAVI) or replacement has rapidly changed the treatment of patients with severe symptomatic aortic stenosis. It is now the standard of care for patients believed to be inoperable or at high surgical risk, and a reasonable alternative to surgical aortic valve replacement for those at intermediate surgical risk. Recent clinical trial data have shown the benefits of this technology in patients at low surgical risk as well. This update of the 2012 Canadian Cardiovascular Society TAVI position statement incorporates clinical evidence to provide a practical framework for patient selection that does not rely on surgical risk scores but rather on individual patient evaluation of risk and benefit from either TAVI or surgical aortic valve replacement. In addition, this statement features new wait time categories and treatment time goals for patients accepted for TAVI. Institutional requirements and recommendations for operator training and maintenance of competency have also been revised to reflect current standards. Procedural considerations such as decision-making for concomitant coronary intervention, antiplatelet therapy after intervention, and follow-up guidelines are also discussed. Finally, we suggest that all patients with aortic stenosis might benefit from evaluation by the heart team to determine the optimal individualized treatment decision.

Résumé

L’implantation valvulaire aortique par cathéter (TAVI) a rapidement modifié le traitement des patients atteints de sténose aortique symptomatique grave. Elle constitue maintenant la norme de soins chez les patients jugés inopérables ou présentant un risque chirurgical élevé, de même qu’une solution de rechange raisonnable à la chirurgie de remplacement valvulaire aortique en présence d’un risque chirurgical intermédiaire. Les données d’essais cliniques récents ont aussi montré les avantages de cette technologie dans un contexte de faible risque chirurgical. Cette mise à jour de l’énoncé de position sur le TAVI publié en 2012 par la Société canadienne de cardiologie (SCC) intègre des données cliniques probantes constituant un cadre de référence pratique pour la sélection des patients, fondé non pas sur le score de risque chirurgical, mais plutôt sur l’évaluation individualisée des risques et des avantages respectifs de l’intervention TAVI et de la chirurgie de remplacement valvulaire aortique chirurgicale. En outre, cet énoncé de position intègre de nouvelles catégories de temps d’attente et de nouveaux objectifs en matière de calendrier de traitement pour les patients sélectionnés en vue d’une intervention TAVI. Les exigences des établissements et les recommandations en matière de formation et de maintien des compétences des chirurgiens ont également été révisées de manière à refléter les normes courantes. Diverses considérations liées à l’intervention sont également examinées, notamment la prise de décisions touchant une intervention coronarienne concomitante, la mise en route d’un traitement antiplaquettaire après l’intervention et les lignes directrices en matière de suivi. Enfin, nous abordons le concept d’une évaluation effectuée par l’équipe de cardiologie qui permettrait d’optimiser les décisions thérapeutiques sur une base individuelle et qui pourrait s’avérer avantageuse dans tous les cas de sténose aortique.

Section snippets

Methods

This document was developed in accordance with CCS best practices and in accordance with the Framework for Application of Grading of Recommendations, Assessment, Development, and Evaluation (see https://www.ccs.ca/images/Development_Process/CCS_GRADE_Framework_June2015.pdf for details). A systematic review of the literature was performed to evaluate TAVI program considerations, patient selection, and procedural and postprocedure guidelines. The primary panel voted on all recommendations and

TAVI penetration and wait times

At this time, there are 28 TAVI centres in Canada. Despite the growth in TAVI demand, available data suggest that TAVI remains relatively underutilized on the basis of estimates of penetration obtained from data in the CCS TAVI Quality Report (2014-2017), despite an increase from 34 to 47 cases per million population.4 In comparison, the rates of TAVI in Europe have increased dramatically from 38 per million in 2011 in France to 155 per million in 2016.5 The penetration rate is a metric of use

Patient Selection

Because of the long experience and large body of clinical data, surgical aortic valve replacement (SAVR) has been recognized as the standard of care for patients with symptomatic AS. However, more than 15 years have passed since TAVI was introduced,19 more than 500,000 procedures have been performed worldwide, and more 8000 published reports have clarified the benefits and risks associated with TAVI. Outcomes have steadily improved as a result of advances in technology, techniques, experience,

Preprocedure evaluation

The TAVI procedure requires a number of preparatory evaluations that confirm the clinical indication and anatomical suitability for TAVI. A transthoracic echocardiogram confirms the severity of AS and morphology of the valve. Electrocardiogram (ECG)-gated CT angiography (CTA) is a core element of TAVI procedural planning for accurate prosthesis sizing and prediction and avoidance of cardiac and vascular complications.58 Systolic reconstruction of the annulus orthogonal to the centre axis of the

Conclusion

TAVI is an important treatment option for patients with severe AS. Because of the recent changes and evolving indications for TAVI in the management paradigm of AS, the current focus should be on improving quality of care by increasing access to therapy, minimizing wait times, and measuring and reporting outcomes to provide optimal patient results.

Acknowledgements

The authors extend their sincere appreciation to the members of the Secondary Panel (collaborators: David Bewick, MD, Michael Chu, MD, Malek Kass, MD, Laurie Lambert, PhD, Michael Mack, MD, Mark Peterson, MD, David Wood, MD) and the CCS Guidelines Committee, who supported this work.

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    The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.

    This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

    These authors contributed equally to this work.

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