Society Position Statement2019 Canadian Cardiovascular Society Position Statement for Transcatheter Aortic Valve Implantation
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.
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These authors contributed equally to this work.