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Take a look at a selection of our recent media coverage:

Impact of COVID-19 on TAVI and the management of patients with severe symptomatic aortic stenosis

10th August 2021

Aortic stenosis and a backlog of care

COVID‐19 has had an unprecedented impact on the management of patients with aortic valve disease since non-urgent cardiovascular diagnostics and interventions were deferred.1–3 Delays in treatment are leading to a growing number of patients waiting for treatment with longer wait times.2,4 The consequences of such delays include death within the perioperative period and poor operative outcomes.1,4–7 It is estimated that as much as 50% of cancelled or delayed procedures may result in significant harm;6 therefore, delays in elective procedures to treat severe symptomatic aortic stenosis (ssAS) contribute to a hidden mortality rate of COVID-19.8 This is creating a wave of pressure on healthcare resources and personnel;4 reconsideration of these patients for transcatheter aortic valve implantation (TAVI) may help to prevent such complications as well as offering patient and organisational benefits1

Diverting ssAS patients to TAVI during COVID-19

COVID-19 has had a significant impact on therapeutic options for ssAS patients undergoing aortic valve replacement (AVR).3

During the pandemic, hospitals have initiated protocols that favour management options that minimise the use of (a) anaesthesiologists, (b) ventilators, (c) operating rooms, and (d) intensive care unit beds. While  surgical AVR (SAVR) require all these elements, TAVI does not1,6—using widely described ‘minimalist’ methodology.6,9–11 Guidelines for ssAS patients during the COVID-19 pandemic have, therefore, included the principle that patients who may have been accepted for sAVR could be ‘diverted’ to TAVI under the guidance of the Heart Team.1,2 SAVR has been the treatment choice in AS for decades, nevertheless, TAVI and especially TAVI with transfemoral access, has become a reliable and effective treatment option.1 This has formed a cornerstone of recommendations for TAVI practice during COVID-19.12

The adoption of a minimalist TAVI approach as the preferred default strategy is an imperative to promote access to care in the ‘new normal’ as COVID-19 continues to dictate the priorities of care.4 Perek et al. report that, from their hospital experience, in the years preceding the pandemic (2018 and 2019), approximately 50% of patients underwent SAVR; this rate dropped to 34% during COVID-19 (2020), demonstrating a shift in procedure from SAVR to minimally invasive TAVI.3 Alongside this shift, Joseph et al. report that there was a significant increase in the proportion of SAPIEN 3™ valves inserted (34 vs 68%, p = 0.001).12 During 2020, patients with AS were younger and had a lower calcification burden compared with pre-pandemic practice, making these patients more suitable for the SAPIEN 3™ valve, accounting for the increase in the use of the SAPIEN 3™ valve.12

Improved organisational and patient benefits of TAVI during COVID-19

COVID-19 cardiology guidelines were based on the accumulation of scientific evidence from clinical trials evidencing that minimally invasive TAVI is a safe and efficacious procedure with low complication rates, shorter length of hospital stay, reduced mortality and minimal stroke rate at 30 days, compared with SAVR.3,9–11 TAVI enables patients to rapidly derive significantly improved quantity and quality of life, regardless of surgical risk profile.2,4 From the patient’s standpoint, TAVI is preferable to SAVR, given shorter hospitalisation and consequent exposure of patients to COVID-19 in hospital and rehabilitation centers.8 This is also true from an organisational viewpoint, undoubtedly conserving resources relative to SAVR.8

Joseph et al. report that TAVI can be undertaken safely during the COVID-19 pandemic with 30-day event rates similar with published clinical trials and international registries.12 No statistically significant difference was noted in peri-procedural complications and 30-day outcomes, while post-operative length of stay was significantly reduced (2 vs 3 days, p < 0.0001) when compared with pre-COVID-19 practice.12

COVID-19 expedited a trend that is expected to continue

The rapid onset of halting referrals and procedures to create capacity to manage the COVID-19 pandemic will be followed by the resumption of access to care under drastically different circumstances, as the world emerges from the pandemic into a ‘new normal’.4 Addressing the escalating needs of patients with cardiovascular disease who are awaiting treatment presents the next challenge for healthcare systems across regions.4 Along with an understanding of the dynamic constraints on healthcare systems, minimalist TAVI can potentially help to further reduce post-care utilisation of resources and allow early patient recovery at home.5

The COVID-19 pandemic has acted as a catalyst for change in healthcare systems worldwide. Resulting adaptations ought to be perceived as opportunities for sustained change and not as temporary disruptions to an often empirically derived TAVI service framework.12 For patients with severe aortic stenosis, efforts to bring treatment to patients amid this pandemic might lead to favoured use of catheter-based management using minimalist techniques.6 As the pandemic abates, TAVI programmes cannot expect a ‘flipping of the switch’ back to pre-pandemic status.4 TAVI programmes must facilitate access to care without compromising patient safety, enable hospitals to manage the competing demands created by COVID-19 and establish new processes to support patients living with valvular heart disease.4

Cost remains a significant barrier to the widespread adoption of TAVI by publicly-funded services outside the pandemic setting; however, incorporating minimalist TAVI has the potential to further improve the cost-effectiveness of a TAVI service.12 There is a compelling need to facilitate the rapid adoption of best practices adapted to the unique demands created by COVID-19 and leverage existing evidence to minimise healthcare resources, facilitate accelerated treatment of AS without compromising patient safety and ensure that patients return home to enjoy the benefits that TAVI affords.4


References

  1. Harky A, Seyedzenouzi G, Sanghavi R, et al. COVID‐19 and its implications on patient selection for TAVI and SAVR: Are we heading into a new era? J Card Surg 2021;36:265-267.
  2. Khialani B, MacCarthy P. Transcatheter management of severe aortic stenosis during the COVID-19 pandemic. Heart 2020;106:1183-1190.
  3. Perek B, Olasinska-Wisniewska A, Misterski M, et al. How the COVID-19 pandemic changed treatment of severe aortic stenosis: a single cardiac center experience. J Thorac Dis 2021;13:906-917.
  4. Lauck S, Forman J, Borregaard B, et al. Facilitating transcatheter aortic valve implantation in the era of COVID-19: Recommendations for programmes. European Journal of Cardiovascular Nursing 2020;19:537-544.
  5. Basman C, Kliger CA, Pirelli L, et al. Management of elective aortic valve replacement over the long term in the era of COVID-19. European Journal of Cardio-Thoracic Surgery 2020;57:1029-1031.
  6. Mehta JJ, Patel J, Ayoub B, et al. Caution regarding potential changes in AVR practices during the COVID‐19 pandemic. J Card Surg 2020;35:1168-1169.
  7. Ro R, Khera S, Tang GHL, et al. Characteristics and Outcomes of Patients Deferred for Transcatheter Aortic Valve Replacement Because of COVID-19. JAMA Netw Open 2020;3:e2019801.
  8. Sundt TM. Managing Aortic Stenosis in the Age of COVID-19: Preparing for the Second Wave. JAMA Netw Open 2020;3:e2020368.
  9. Wood D. The Vancouver 3M (multidisciplinary, multimodality but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers. JACC: Cardiovascular Interventions 2019;12:459-69.
  10. Barbanti M, van Mourik MS, Spence MS, et al. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. EuroIntervention 2019;15:147-154.
  11. Lauck SB, Wood DA, Baumbusch J, et al. Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway: Minimalist Approach, Standardized Care, and Discharge Criteria to Reduce Length of Stay. Circ Cardiovasc Qual Outcomes 2016;9:312-321.
  12. Joseph J, Kotronias RA, Estrin-Serlui T, et al. Safety and operational efficiency of restructuring and redeploying a transcatheter aortic valve replacement service during the COVID-19 pandemic: The Oxford experience. Cardiovascular Revascularization Medicine 2020:S1553838920307855.

For professional use. For a listing of indications, contraindications, precautions, warnings, and potential adverse events, please refer to the Instructions for Use (consult eifu.edwards.com where applicable).

Edwards devices placed on the European market meeting the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/EEC bear the CE marking of conformity.

©2021 Edwards Lifesciences Corporation. All rights reserved. PP–EU-2599 v1.0

Transcatheter aortic valve implantation efficiency programs: Optimised TAVI pathways

2nd July 2021

Rapid expansion in the use of TAVI has led to continuing improvements in techniques and clinical outcomes, but this has also presented a new problem: treating a larger cohort of patients in a more efficient way with shorter procedures and shorter hospital stays, while maintaining excellent outcomes.1 Minimalist TAVI approaches have been shown to have distinct advantages without compromising patient safety.2-4 Consequently, there is an increasing need to simplify the TAVI procedure, and practice recommendations have been adopted to support the patient’s journey from referral to discharge.1

An optimised TAVI pathway embodies efficient patient screening, a minimalist peri-procedure approach and early discharge – eliminating complication risks and without compromising patient outcomes.1

Establishing a multidisciplinary heart team 

International guidelines recommend establishing a multidisciplinary heart team to screen patients for TAVI;5 this collaborative process has been deemed essential in establishing a successful TAVI efficiency programme.6,7 The heart team fosters collaboration across medical specialities to offer optimal patient-centered care,8 and has been shown to improve outcomes in TAVI procedures, making use of diverse competencies. The heart team guides patient selection, optimises patients’ pre-procedure status, facilitates early discharge and provides continuity of care.6,7

The multidisciplinary team includes any of interventional cardiologists, cardiothoracic surgeons, imaging specialists, nurses, anaesthesiologists, occupational therapists, social workers, and administrative staff.6-8 A key team member is the clinician who leads the coordination and streamlining of the TAVI programme, facilitating patient-focused processes of care for both out- and in-patient settings, and fostering communication: the TAVI co-ordinator.6,9

Members of the heart team work collaboratively and should be co-located at heart valve centres: centres of excellence for diagnostics and treatment of valvular heart disease.10 Many centres of excellence that have implemented a TAVI efficiency programme include dedicated TAVI teams that incorporate the concept of the heart team.2 These TAVI teams will have expertise in TAVI along with basic peripheral vascular intervention skills.6

Peri- and post-procedure

A TAVI efficiency programme focuses on avoiding inessential treatment steps and minimising human resource needs during the procedure.1 Transfemoral TAVI is used in >90% of cases,1 and maximising transfemoral access is important when trying to maximally exploit the benefits of a minimalist TAVI approach.1-3

Priorities of post-procedure care include vigilant monitoring of recovery, facilitating the rapid return of patients to baseline status and preventing complications.3,4 Discharge inside of 72h has been reported in >70% of patients when a minimalist TAVI approach has been adopted.3,4 Adequate patient follow-up ensures comprehensive patient management and decreased complication rates.3 It has been reported that early ambulation (6h post-procedure) results in early discharge, which helps to ensure adequate turnover of uncomplicated patients.1

Optimised TAVI pathways: Partnering with Industry

While TAVI has been found to have higher procedural costs compared with SAVR, driven primarily by the costs associated with the valve, this is offset by a decrease in healthcare resource utilisation. The overall costs (initial procedure and hospitalisation) have been reported to be lower for TAVI than for SAVR: this makes TAVI dominant compared with SAVR from a health economic perspective.11

As such, metrics for a TAVI efficiency programme encompass patients’ quality of life, clinical outcomes, length of stay, resource utilisation, and cost-effectiveness.6,7 TAVI efficiency leads to reduced procedural time, shorter ICU and hospital stay, lower resource use and hospital costs, and increased volume of TAVI procedures – conferring an overall cost-saving for TAVI compared with SAVR.1,11

When it comes to TAVI efficiency programmes, it is suggested that stakeholders collaboratively devise a plan for evaluating the success and sustainability of the programme,6,8 since inefficiencies, practice variation and imprecise decisions in Heart Teams are inevitable. Several heart centres around the world have high volume TAVI workloads and provide training and subsequent proctoring services.12 One such service is the Edwards Benchmark ProgramTM, provided by Edwards Lifesciences.

The Edwards Benchmark ProgramTM consolidates clinical best practices into an educational transformation pathway for hospitals and adopts the minimalist TAVI pathway to improve patient outcomes and access to TAVI procedures.13 The Benchmark program™ is a standardised care pathway to achieve consistently excellent outcomes; it is a reproducible and scalable programme designed to optimise the patient pathway from admission to discharge.13

Objectives of the Benchmark ProgramTM include <1% 30-day mortality and stroke, >80% next-day discharge home and <4% 30-day cardiovascular readmissions.13 Many European centres have been successfully enrolled into the Benchmark Program™, with consistent reduction in average length of stay and increases in the number of TAVI cases performed per day.13 As evidence-based practice becomes increasingly important, the Edwards Benchmark ProgramTM will help to make the patient journey from referral to discharge more efficient and more importantly, confer cost-savings to organisations by reducing healthcare resource utilisation.


References:

  1. Tchetche D, et al. How to make the TAVI pathway more efficient. Interv Cardiol 2019;14:31–33. 
  2. Lauck SB, et al. Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway. Minimalist Approach, Standardised Care, and Discharge Criteria to Reduce Length of StayCirc Cardiovasc Qual Outcomes 2016;9:312–21.  
  3. Wood DA, et al. The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical Pathway Facilitates Safe Next-Day Discharge Home of Low-, Medium-, and High-Volume Transfemoral Transcatheter Aortic Valve Replacement Centres. JACC Cardiovasc Interv 2019;12:459–69. 
  4. Barbanti M, et al. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. Euro Intervention 2019;15:147–54. 
  5. ESC/EACTS guidelines. European Heart Journal 2017;38:2739-91.
  6. Hawkey MC, et al. Transcatheter aortic valve replacement program development: recommendations for best practice. Catheterization and Cardiovascular Interventions 2014;84:859–67.
  7. Walters DL, et al. Position Statement for the Operator and Institutional Requirements for a Transcatheter Aortic Valve Implantation (TAVI) Program. Heart, Lung and Circulation 2014;1–5.
  8. Clarke S, et al. Using clinical decision support and dashboard tech to improve heart team efficiency and accuracy in TAVI program. Nursing Informatics 2016; doi:10.3233/978-1-61499-658-3-98.
  9. Derk Frank, Insights into the Edwards Benchmark program, PCR London Valves 2019. 
  10. ESC. TAVI 2018: from guidelines to practice. Available from: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/TAVI-2018-from-guidelines-to-practice. Accessed April 2021.
  11. Zhou J, et al. Cost-effectiveness of transcatheter aortic valve implantation compared to surgical aortic valve replacement in the intermediate surgical risk population. 2019;139:877-88.
  12. Vallely MP, et al. How to set up a successful TAVI program 2012; doi: 10.3978/j.issn.2225-319X.2012.06.04.

An introduction to aortic stenosis, the population health burden and the TAVI pathway

27th May 2021

Aortic stenosis physiology

The heart is composed of four chambers (aorta and ventricles) and two valves: the mitral valve is between the left atrium and ventricle, and the tricuspid valve is between the right atrium and ventricle.1,2

There are a further two valves in the large blood vessels (the pulmonary artery and the aorta) that leave the heart: the aortic and pulmonic valves.1,2The heart valves ensure that blood flows through the heart in one direction and does not flow back into the heart once it has been pumped out.1 The heart pumps oxygenated blood through the aortic valve in the aorta to the rest of the body.3                                                                                   

                Figure adapted from New Heart Valve4

The aortic valve is comprised of thin leaflets that open and close to regulate blood flow.4 Over time, the valve leaflets can thicken, narrow and stiffen, resulting in the aortic valve failing to open and close properly. As the opening in the valve becomes smaller, the heart becomes less effective and pumps less blood out to the rest of the body. This is termed ‘aortic stenosis’ (AS),3,5,6and it is the most common valvular disease in developed countries among the elderly with a prevalence of 1-3% among those >70 years of age.7 If left untreated, aortic stenosis can lead to compromised heart function, heart failure and death.3,7

Aortic stenosis progession

Aortic stenosis is a progressive disease and is categorised as mild, moderate or severe, depending on how much damage there is to the aortic valve.7,8 During mild or moderate stages, patients may remain asymptomatic with no noticeable symptoms and may be told that they have a heart murmur during routine check-ups.7,8 Advice for patients with mild or moderate asymptomatic AS is watchful waiting and to maintain a healthy lifestyle.3,9

As stenosis worsens, there is an increase in pressure in the left ventricle, causing the muscle to enlarge as a compensatory mechanism (termed ventricular hypertrophy) to maintain cardiac output.5,7,9,10As the disease progresses, this compensatory mechanism becomes inadequate, leading to symptoms of pulmonary oedema or heart failure.7,9,10Once AS becomes severe, noticeable symptoms may appear such as fatigue, shortness of breath, chest pain, heart palpitations; dizziness, syncope, or oedema of the feet and ankles.3,5,7,11

                                                                Figure adapted from New Heart Valve4

Population health burden of aortic stenosis

Although the condition can be asymptomatic for years, when symptoms do appear, untreated patients with severe AS have high mortality (up to 50% within 2 years).12,13 Waiting for treatment for severe symptomatic AS (ssAS) has a 1-month mortality at 3.7% and a 6-month mortality at 11.6% (measured from the time intervention was recommended).14

With a growing and ageing population, the prevalence of valvular heart disease is expected to rise, further increasing the public health burden of the disease.15

TAVI: a cost-effective intervention

For severe symptomatic aortic stenosis, aortic valve replacement (AVR) should be recommended, which can include surgical repair or a less invasive procedure such as transcatheter aortic valve implantation (TAVI).3,7

TAVI is a minimally invasive interventional cardiology procedure catheter-based treatment that is performed under local rather than general anaesthetic.7,16The principle of TAVI is the insertion of a balloon-expandable valve inside the old valve, without the need to remove it.7 A catheter is inserted through a small incision in the groin (transfemoral TAVI) or via the left-hand side of the chest (transapical TAVI). The valve, which sits inside a stent is crimped onto the end of the catheter, and when in place, a small balloon is inflated, which allows the valve to expand.5,16Once expanded, the new valve displaces the native valve leaflets outward and takes over the regulation of blood flow across the aortic valve.7 TAVI significantly improves symptoms and potentially increases life expectancy and quality of life, without the need for open heart surgery.5,16

Clinical trial data have demonstrated that transcatheter AVR (TAVR) for inoperable patients extends median survival by approximately 19 months and significantly improves quality of life compared with medical therapy alone.12 In the same study, it has been suggested that substantial social value can be created as a result of TAVR treatment for these patients: up to $48.1 billion in value, roughly 80% of which accruing to patients (and 20% to device manufacturers).12 Using data from the PARTNER B trial,17 Reynolds and colleagues found that patients with ssAS considered to be at a high surgical risk who underwent TAVR experienced lifetime incremental cost-effectiveness ratios of $55,090 per quality-adjusted life year (QALY) gained and $43,114 per life-year gained.18 Such a perspective is useful for payers and policy makers because it extends the decision-making considerations concerning TAVR adoption beyond a narrow evaluation of short-term cost.


References

  1. British Heart Foundation. Heart valve disease. Available from: www.bhf.org.uk/informationsupport/conditions/heart-valve-disease. Accessed April 1, 2021.
  2. Cleveland clinic. Heart Valves. 2018. Available from: https://my.clevelandclinic.org/health/articles/17067-heart-valves. Accessed April 1, 2021.
  3. American Heart Association. Aortic Stenosis. 2020. Available from: https://www.heart.org/-/media/files/health-topics/heart-valve-disease/aortic-stenosis-fact-sheet.pdf?la=en. Accessed April 1, 2021.
  4. New Heart Valve. What is aortic stenosis? 2021. Available from: https://newheartvalve.com/uk/understand-your-heart/what-is-aortic-stenosis/. Accessed April 1, 2021.
  5. NHS. Diagnosis and treatment: aortic stenosis. 2014. Available from: https://www.uhs.nhs.uk/OurServices/Bloodandcirculation/Transcatheter-aortic-valve-implantation/Diagnosis-and-treatment-TAVI/Diagnosis-and-treatment-TAVI.aspx. Accessed April 1, 2021.
  6. WebMD. What is Aortic Valve Stenosis? 2021. Available from: https://www.webmd.com/heart-disease/aortic-valve-stenosis. Accessed April 1, 2021.
  7. Zakkar M, Bryan A, Angelini G. Aortic stenosis: diagnosis and management. BMJ. 2016;355:i5425.
  8. WebMD. How severe is your aortic stenosis? 2019. Available from: https://www.webmd.com/heart-disease/aortic-stenosis-stages. Accessed April 1, 2021.
  9. Grimard B, Larson J. Aortic stenosis: diagnosis and treatment. Am Fam Physician. 2008;78(6):717-724.
  10. Kamperidis V, Delgado V, Van Mieghem N, Kappetein A, Leon M, Bax J. Diagnosis and management of aortic valve stenosis in patients with heart failure. European journal of heart failure. Eur J Heart Fail. 2016;18(5):469-481.
  11. Heart Valve Voice. Aortic Stenosis. Available from: https://heartvalvevoice.com/heart-valve-disease/the-condition/aortic-stenosis. Accessed April 1, 2021.
  12. Sussell J, Van Eijndhoven E, Schwartz T, et al. Economic Value of Transcatheter Valve Replacement for Inoperable Aortic Stenosis. Am J Manag Care. 2020;26(2):e50-e56.
  13. Otto C. Timing of Aortic Valve Surgery. Heart. 2000;84(2):211-218.
  14. Malaisrie S, McDonald E, Kruse J, et al. Mortality While Waiting for Aortic Valve Replacement. Ann Thorac Surg. 2014;98(5):1564-1571.
  15. Moore M, Chen J, Mallow P, Rizzo J. The direct health-care burden of valvular heart disease: evidence from US national survey data. Clin Outcomes Res. 2016;8:613-627.
  16. NHS. Transcatheter aortic valve implantation (TAVI) procedure. 2020. Available from: https://www.kch.nhs.uk/Doc/pl%20-%20859.3%20-%20transcatheter%20aortic%20valve%20implantation%20(tavi)%20procedure.pdf. Accessed April 1, 2021.
  17. Edwards Lifesciences. THE PARTNER TRIAL: Placement of Aortic Transcatheter Valve Trial (PARTNER). 2017. Available from: https://clinicaltrials.gov/ct2/show/NCT00530894. Accessed April 1, 2021.
  18. Reynolds M, Lei Y, Wang K, et al. Cost-effectiveness of Transcatheter Aortic Valve Repacement with a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement. J Am Coll Cardiol. 2016;67:29-38.

© 2021 Edwards Lifesciences Corporation. All rights reserved. PP–EU-2342 v1.0

How does partnering with Industry benefit your organisation? Implementing TAVI best practices

24th March 2021

Implementing change

Transcatheter aortic valve implantation (TAVI) with the SAPIEN 3TM valve has been granted the CE mark for all-risk patients with severe symptomatic aortic stenosis (ssAS).1

Switching ssAS patients from other treatment methods to the less-invasive TAVI procedure will pave the way to improved hospital efficiency, including shortening waiting lists and length of stay (LOS) and lowering re-hospitalisation rates, which is of paramount importance during and post-COVID-19,2 as hospitals face tackling the backlog of patients whose care have been placed on hold while hospital resources have been restructured during the pandemic.3

Streamlining the TAVI pathway

Many studies have consolidated best practices to develop, implement and evaluate a standardized clinical pathway to facilitate safe discharge home at the earliest time after TAVI. These studies aimed to create clinical pathway protocols that supplement the TAVI procedure with the SAPIEN 3TM valve.4-6

Opportunities were first identified to adopt minimalist practices, standardizing post-procedure care, decreasing patients’ length of stay and facilitating safe discharge to home.4 An expanded multidisciplinary heart team designed a comprehensive TAVI clinical pathway that followed the patients’ journey from admission to discharge; the role of the multidisciplinary heart team is invaluable in implementing quality innovation that entails minimalist peri-procedure practices and facilitates early discharge home for patients with ssAS.4 The risk-stratified criteria that was identified informed the development of the multimodality, multidisciplinary but minimalist TAVR (3M TAVR) study.4,5

The barriers to implementing the TAVI clinical pathway were challenging and grounded in historical practices, the complexity and disciplines engaged in the care of TAVI patients, the adoption of length of stay as a programme quality indicator and the operational challenges of implementing peri-procedure practices.5 These barriers were addressed by an expanded multidisciplinary heart team approach that captured the patient’s journey from admission to discharge, in the form of a TAVI Care Team.

This multidisciplinary Care Team enabled communication and discussion of all operational and practice issues related to the clinical pathway initiative; identification of educational initiatives for members of the team; engagement and support of all multidisciplinary stakeholders, all of whom were focused and aligned on the adaptation of new processes, improved outcomes and reduced demand on health service resources; and implementation of practice changes involving the transition to minimalist care.

Consolidating TAVI organisational efficiencies, the results demonstrated that a minimalist, streamlined TAVI pathway with the Edwards Lifesciences SAPIEN 3TM valve, with rapid remobilisation, allows for next-day discharge home, with reproducible, excellent safety and efficiency outcomes. Next-day discharge and 48h discharge was achieved in 80% and 90% of TAVI patients, respectively, and amid concerns that a minimalist approach may affect safety or clinical efficacy, the composite primary endpoint of all-cause mortality or stroke by 30 days occurred in 2.9% of TAVI patients.5

This minimalist clinical pathway that utilised pre-specified risk criteria to allow a safe and timely discharge of patients with ssAS undergoing TAVI, was validated by the European FAST-TAVI trial in 2019. The trial found that the 30-day complication risk did not increase when pre-specified risk criteria was used.6   

                                                                                                                                   Figure from Wood et al. (2019)5

Partnering with industry

There are three key areas on which collaboration between Industry and hospitals might be based: evidence, tracking and technology. (Cogora, in-house data

There is a significant body of TAVI literature that illustrates pre-, peri- and post-procedure processes that positively impact on the safety and efficiency of partnering with Industry. However, these processes can vary from site-to-site and operator-to-operator. 

In Edwards Lifesciences, hospitals have a partner that has further consolidated these examples of best practice to create the Edwards BenchmarkTM Programme: an educational standardised care pathway (from admission to discharge) that optimises the TAVI clinical pathway with a programme designed to deliver good, reproducible patient outcomes and access, and improved institutional capacity driven by proven best practice.7


References

  1. Whooley S. Edwards’ Sapien 3 TAVI wins expanded approval in Europe. 2019. Available at: https://www.massdevice.com/edwards-sapien-3-tavi-wins-expanded-approval-in-europe/. Accessed April 2021.
  2. ESC. ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. 2020. Available from: https://www.escardio.org/static_file/Escardio/Education-General/Topic%20pages/Covid-19/ESC%20Guidance%20Document/ESC-Guidance-COVID-19-Pandemic.pdf. Accessed April 2021.
  3. The Health Foundation. Elective care in England: Assessing the impact of Covid-19 and where next. 2020. Available at: https://www.health.org.uk/publications/long-reads/elective-care-in-england-assessing-the-impact-of-covid-19-and-where-next. Accessed April 2021.
  4. Lauck SB, et al. Vancouver Transcatheter Aortic Valve Replacement Clinical Pathway. Minimalist Approach, Standardised Care, and Discharge Criteria to Reduce Length of Stay. Circ Cardiovasc Qual Outcomes 2016;9:312–21.
  5. Wood DA, et al. The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical Pathway Facilitates Safe Next-Day Discharge Home of Low-, Medium-, and High-Volume Transfemoral Transcatheter Aortic Valve Replacement Centres. JACC Cardiovasc Interv 2019;12:459–69.
  6. Barbanti M, et al. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. Euro Intervention 2019;15:147–54.
  7. Derk F, Insights into the Edwards Benchmark program, PCR London Valves 2019.

© 2021 Edwards Lifesciences Corporation. All rights reserved. PP–EU-2172 v1.0

Optimising organisational efficiencies in the treatment of patients with severe, symptomatic aortic stenosis

Eligible TAVI population and a backlog of care

Healthcare organisations have been reconfigured in response to the COVID-19 pandemic, including cancellations of elective procedures, which has resulted in one of the largest official waiting lists on record. There were 4.5 million patients waiting to complete treatment as of December 2020, with 4.7 million fewer completed patient pathways in 2020 vs 2019. Additionally, with 5.9 million referrals fewer in 2020 compared with 2019, there is the concept of the ‘hidden’ waiting list since many of these patients will still require treatment.1

Along with Edwards SAPIEN 3TM Transcatheter Heart Valve (THV) being CE-marked for use in all-risk patients,2-5 and increasing the number of patients eligible for TAVI as a consequence,6 the ongoing COVID-19 pandemic is undoubtedly adding to the increasing ssAS patient population who are eligible for TAVI.7
As COVID-19 restrictions are lifted, the priority for healthcare organisations will be to address the backlog of patients whose care has been placed on hold,8 and TAVI treatment for patients with ssAS has unique organisational benefits that will help healthcare organisations improve organisational efficiency with derivative economic benefits.7

It has been reported that during the peak of the pandemic, ssAS patients who were previously accepted for SAVR were being reconsidered for TAVI.7 Given the increased demand on healthcare resources during the pandemic, TAVI offers unique organisational advantages over SAVR since it is minimally invasive with lower complication rates, enabling faster recovery, shorter length of stay and conservation of resources;7,9 during the pandemic, clinical practice was guided by the large and well-established evidence base of TAVI in patients with severe aortic stenosis.10

Therefore, the COVID-19 pandemic has highlighted the organisational benefits of TAVI vs SAVR. The clinical practice changes observed during the pandemic were based on well-established evidence of TAVI vs SAVR gained outside of a global pandemic environment; this suggests that the pandemic highlighted the existing benefits of TAVI and that these benefits may well extend beyond the pandemic.7,9,10

Improving hospital efficiency

Consequently, in the hospital, the TAVI-led efficiencies in the management of ssAS patients may have a significant economic benefit when the patient pathway is optimised. As demonstrated in the 3M TAVI study, optimising the patient pathway has benefits for the hospital such as early discharge and excellent patient outcomes, which ultimately, might lead to financial benefits, improved waiting lists and less demand for beds.15

TAVI-led efficiencies with the Edwards Lifesciences SAPIEN 3™ valve can support hospitals with this, and the transition from SAVR to TAVI presents clear opportunities to improve organisational efficiency by: (1) minimising procedural time;5 (2) lowering the rates of complications5,16 (3) reducing the length of hospital stay without compromising safety;5,17 (4) reducing the rate of re-hospitalisation;5,18 (5) shortening waiting lists and (6) lessening demand on rehabilitation beds. 

To counter the ever-increasing waiting list of patients,1 there is a proven need to increase hospital efficiencies, including lowering in-hospital complications to improve outcomes for patients as well as increasing access to beds for other patients.11 More importantly, improved efficiency and lower complication rates will improve patient waiting times: studies have shown that increased patient times can adversely affect patient mortality and morbidity while patients wait for intervention.12-14

Organisational benefits of TAVI

Minimising procedural time
Organisational benefits of TAVI

Procedure time (in minutes) has been shown to be reduced from 208.3 for SAVR to 58.6 for TAVI.5
Cost savings

More patients can be treated daily in one cath-lab/hybrid room, or costs can be cut by reallocating / releasing staff.5
Lowering the rates of complications
Organisational benefits of TAVI

In-hospital complications such as bleeding complications, severe kidney failure, and implantation of a second valve19 lead to inefficiencies, such as increased LOS consumption of additional resources and blocked access to hospital beds for other patients.11
Cost savings

This adds to the hospital’s expenditure for additional nursing time, diagnostics, and pharmaceuticals before possible discharge.11 Potential cost savings that result from lower complication rates compared with surgery have been quantified with the SAPIEN 3 valve at ~€40005,16,19
Reducing the length of hospital stay without compromising safety
Organisational benefits of TAVI

LOS was reported to be 3 and 7 days for TAVI and SAVR, respectively.5,16 Studies report safe discharge home ≤72h in 73% of TAVI patients, with 27% of these ≤24h and 51% ≤ 48h20 Across the EU, the mean LOS for TAVI patients ranges from 5 (France)21 to 14.5 (Germany) (data on file, Edwards Lifesciences). The UK mean is reported to be 5.5.22
Cost savings

The TAVI minimalist approach limits direct procedural costs (estimated at a saving of ~€4000 over SAVR).5,16,23 More importantly, it shortens the median LOS (a saving of ~€1000 over SAVR for intensive care unit LOS, and ~€1900 for ward LOS,5,16,24 thereby minimising post-procedure costs.17
Reducing the rate of re-hospitalisation
Organisational benefits of TAVI

Readmission after cardiac procedures is common and contributes to increased healthcare use.18 The primary cause of cardiac re-hospitalisation is heart failure,18 for which the median LOS is 4 days.25 The SAPIEN 3 valve leads to less hospitalisation at 30 days compared with SAVR, and it is the only TAVI system superior to SAVR for all-cause death, all stroke and re-hospitalisation at 1 year (8.5% versus 15.1%).5
Cost savings

Re-hospitalisation has hospital costs in terms of staff, beds and procedural resources and lowering re-hospitalisation rates allows these resources to be allocated elsewhere, increasing hospital efficiency, and lowering waiting lists, leading to better outcomes for patients.11

References

  1. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019;380:1695–705.
  2. Leon MB, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609–20.
  3. Smith CR, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:2187–98.
  4. Durko AP, et al. Annual number of candidates for transcatheter aortic valve implantation per country: current estimates and future projections. Eur Heart J 2018;0:1-8.
  5. Lagoe RJ and Westert GP. Evaluation of hospital inpatient complications: a planning approach. BMC Health Services Research 2010;10:200.
  6. Bhattacharyya S. Mortality whilst waiting for intervention in symptomatic severe aortic stenosis. Europe Heart Journal – Quality of Care and Clinical Outcomes 2020;6:89–90.
  7. Elbaz-Greener G, et al. Temporal trends and clinical consequences of wait times for transcatheter aortic valve replacement. Circulation 2018;138:483–93.
  8. Malaisrie SC, et al. Mortality while waiting for aortic valve replacement. Anne Thorac Surg 2014;98:1564–70.
  9. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients [supplemental appendix]. N Engl J Med 2019;380:1695–705.
  10. Gutman A, et al. Analysis of the Additional Costs of Clinical Complications in Patients Undergoing Transcatheter Aortic Valve Replacement in the German Health Care System. Int J Cardiol 2015;179:231–23.
  11. Wayangankar SA, et al. Length of stay after transfemoral transcatheter aortic valve replacement: An analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. JACC Cardiovasc Interv 2019;12:422–30.
  12. Barbanti M, et al. Early discharge after transfemoral transcatheter aortic valve implantation. Heart 2015;101:1485–90.
  13. Barbanti M, et al. Optimising patient discharge management after transfemoral transcatheter aortic valve implantation: the multicentre European FAST-TAVI trial. Euro Intervention 2019;15:147–54.
  14. Gilard M. Activité Structurelle en 2018, High Tech 2019. Available from http://www.hightech-cardio.org/usrfile/Presentation/2019/OC-IN009.pdf. Accessed April 2020.
  15. Ludman P, Transcatheter Aortic Valve Implantation UK TAVI Audit Data 2007 to 2017. Available from: http://www.bcis.org.uk/wp-content/uploads/2018/11/TAVI-slide-deck-to-2017-data-15-11-2018.pdf. Accessed April 2020
  16. Kolte D, et al. Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States: Insights From the Nationwide Readmissions Database. Circ Cardiovasc Interv 2017;10:e004472.
  17. Tashtish N, et al. Length of Stay and Hospital Charges for Heart Failure Admissions in the United States: Analysis of the National Inpatient Sample. J Cardiac Failure 2017;23:8 Supplement 1 (S59).
  18. Wood DA, et al. The Vancouver 3M (Multidisciplinary, Multimodality, But Minimalist) Clinical Pathway Facilitates Safe Next-Day Discharge Home of Low-, Medium-, and High-Volume Transfemoral Transcatheter Aortic Valve Replacement Centres. JACC Cardiovasc Interv 2019;12:459–69.

© 2021 Edwards Lifesciences Corporation. All rights reserved. PP–EU-2125 v1.0

Severe symptomatic aortic stenosis patients report improved outcomes with TAVI vs SAVR

Patient-centred care and shared decision making

Increasing treatment alternatives for patients with ssAS at all levels of surgical risk has renewed the focus on incorporating patient values and preferences in a shared decision-making approach.1 There is increasing interest in integrating the patients’ perspective, expectations and motivation in the decision-making process.2 Patient-centred goals may inform selection of treatment options aligned with patient preferences; elicitation of these preferences is paramount to the continued movement towards increased patient-centred care.3

The most reported patient-defined goals in valvular disease are those goals that will lead to a better quality of life. In elderly populations with ssAS, patient treatment goals favour quality of life outcomes over survival, and patient-defined goals include maintaining independence, reducing symptoms, and increasing functional ability.3

These treatment goals mirror the current understanding and healthcare focus on patient-centred care and shared decision-making, which involve symptom burden, the experienced patient, expectations, healthcare support, logistical barriers/facilitators, obligations and responsibilities.2

Patient-defined goals in TAVI

Often overlooked, but equally important, is the absence of data on the patient-defined goals of treatment among low-risk patients with AS.1 Patients with ssAS who are of low surgical risk are young with an increased life expectancy, and therefore, long-term valve durability might be a consideration.4

However, in one study, patients aged <60 and ≥60 years placed a greater value on attributes that favoured TAVR than SAVR, such as a lower mortality rate, reduced procedural invasiveness, and quicker time to return to normal quality of life associated with TAVI, than the value on the time over which SAVR has been proven to work.5 It has been described that patients may define “procedural success” as being able to return home following a rapid return to their baseline mobilization and overall functional status, without experiencing delirium or other iatrogenic complications, and able to recover quickly to benefit from the physiological impact of their new valve.6

How TAVI helps to meet those expectations?

Patient-related benefits and patients’ quality of life have been reported to be better following TAVI compared with SAVR.

Patient length of stay in hospital following TAVI is reportedly shorter compared with SAVR (3 days vs 7 days).7,8 Similarly, there are reduced re-hospitalisation rates reported in TAVI compared with SAVR.7,9 Overall, studies have reported:

  • Quicker discharge home (3 days [TAVI] vs 7 days [SAVR])7,8
  • Faster procedure time with TAVI vs SAVR (58 vs 208 min)7,8
  • Improved health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) instrument (a 38% change from baseline for TAVI compared with 13% for SAVR)7,8
  • Improved 6-minute walk distance (+17.2 metres from baseline with TAVI versus -15.2 for SAVR)7,8
  • Comparable complication-rates with TAVI reported at 30 days compared with SAVR7,9

In short, these patients are home sooner, they feel better faster, and are more active compared with surgical patients, and because patients return home sooner, waiting lists are shorter for their fellow patients (critical in a time of increased need, resulting from all-risk patient suitability): all of which becomes of critical importance during and post the COVID-19 landscape. As hospitals attempt to tackle the backlog of patients whose care has been placed on hold during the pandemic, shorter waiting lists will benefit the hospitals’ efficiency.10

Patients’ satisfaction with their care is inextricably linked to the hospital in which they are treated, and hospital reputations can be enhanced or damaged by the satisfaction feedback of its patients.11 Hospital Boards and Senior Management are rightly attuned to the Voice of its patients – and the broadened, younger cohort of ssAS patients know how to use their Voice. Consequently, it has never been more important for hospitals to prioritise patient satisfaction.11


References

  1. Coylewright M, et al. TAVR in Low-Risk Patients: FDA Approval, the New NCD, and Shared Decision-Making. J Am Coll Cardiol 2020;75:1208-1211.
  2. Lauck SB, et al. Factors influencing the decision of older adults to be assessed for transcatheter aortic valve implantation: An exploratory study. Eur J Cardiovasc Nurs 2015;DOI: 10.1177/1474515115612927.
  3. Coylewright M, et al. Patient‐defined goals for the treatment of severe aortic stenosis: a qualitative analysis. Health Expect 2015;19:1036-43.
  4. Blackman DJ, et al. Long-Term Durability of Transcatheter Aortic Valve Prostheses. J Am Coll Cardiol 2019;73:537-45.
  5. Marsh K, et al. Patient-centered benefit-risk analysis of transcatheter aortic valve replacement. F1000Research 2021;8:394.
  6. Lauck SB, et al. What is the right decision for me?” Integrating patient perspectives through shared decision-making for valvular heart disease therapy. Can J Cardiol 2021. [epub ahead of print]
  7. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019;380:1695–1705.
  8. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients [supplemental appendix]. N Engl J Med 2019;380:1695–705.
  9. Barbanti M, et al. Optimizing patient discharge management after Transfemoral Transcatheter Aortic Valve Implantation: The Multicentre European FAST-TAVI trial. Euro Intervention 2019;15:147–54.
  10. Shafi A, et al. Transcatheter aortic valve implantation versus surgical aortic valve replacement during the COVID-19 pandemic – Current practice and concerns. J Card Surg 2021;36:260-4.
  11. NHS. The patient experience book. Available at: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Patient-Experience-Guidance-and-Support.pdf. Accessed April 2021.

© 2021 Edwards Lifesciences Corporation. All rights reserved. PP–EU-1966 v1.0

TAVI is eligible for the all-risk severe symptomatic aortic stenosis patient population

Introduction

Aortic stenosis (AS) is the most common valvular heart disease in developed countries.1 It presents in 1.3% of the population aged ≥65 years,2 which rises to 4.1-5.2% in the population aged ≥75 years.3

By 2050, the prevalence of AS is expected to have doubled,2 and the impact of AS on health institutions is expected to increase due to the progressive ageing of the population.4

The only currently accepted treatment for symptomatic patients with severe AS (ssAS) is aortic valve replacement (AVR), and without treatment, prognosis is poor with a 3-year survival rate <30%.5 However, it is estimated that 33% of patients aged ≥75 years are declined for treatment, even when indicated.5 Moreover, many older patients are deemed to be of prohibitive risk for surgical aortic valve replacement (SAVR).1

Instead, patients with ssAS could be considered for transcatheter aortic valve implantation (TAVI).1

TAVI for all-risk patients

After the first successful TAVI procedure in 2002,6 >300,000 TAVI procedures have since taken place,7 and numerous prospective trials and observational studies have reported improved survival of TAVI compared with SAVR in prohibitive,8 high,9 intermediate10 and low surgical risk11 patients with ssAS.

In 2010, the first PARTNER trial enrolled patients with ssAS who were not considered candidates for surgical replacement of the aortic valve and found that, compared with standard therapy, TAVI significantly reduced the rates of death from any cause.8

This was followed by a non-inferiority trial that found similar rates of survival at 1 year in high-risk patients with ssAS who were still considered to be candidates for surgery who were assigned to undergo either SAVR or TAVI.9

By 2015, TAVI for inoperable or high-risk patients with ssAS was well established, but real-world evidence showed that 94% of patients with ssAS fall into the low- (80%) or intermediate-risk (14%) categories for whom TAVI was an option, despite a paucity of data.12 Clinical trial validation was provided by the PARTNER trial investigators in 2016, where intermediate-risk patients with ssAS were assigned to undergo either TAVI or SAVR, and no significant difference was reported in the primary end point of death or disabling stroke between TAVI and SAVR.10 This was supported by data from a propensity score analysis in intermediate-risk patients with ssAS that indicated significant superiority of TAVI compared with surgery for the composite outcome of all-cause death, all strokes and moderate to severe aortic regurgitation, suggesting that TAVI might be the preferred treatment alternative in intermediate-risk patients.13

In 2019, the PARTNER 3 trial was designed to address whether TAVI was a viable treatment alternative to SAVR in patients with ssAS of low risk. Patients were randomised to undergo either TAVI or SAVR and the primary endpoint was a composite outcome of death from any cause, stroke or rehospitalisation at 12 months. The rate of the primary endpoint was reported to be significantly lower in the TAVI group than the SAVR group.11

As TAVI moves into the low-risk patient population, an important consideration should be the increased life expectancy of this group, and therefore, the long-term valve durability needs to be understood.14 Long-term data on the function of TAVI valves post-procedure are just emerging but one study reported at a median follow-up of 5.8 years and a maximum of 10 years, long-term function is excellent with 91% of patients not experiencing any structural valve deterioration.14

Expanding population and resource planning

It has been reported that there are 115,000 eligible ssAS candidates for TAVI who are deemed inoperable or of high- and intermediate-risk across the EU. With an ever-increasing ssAS population becoming eligible for TAVI, the expansion into young, low-risk patients as well as promising long-term outcome data, the uptake of TAVI across the EU is expected to increase to as much as 177,000 with major implications for healthcare resource planning.15

The ongoing COVID-19 pandemic is undoubtedly adding to the increasing ssAS patient population who are eligible for TAVI: it has been reported that during the peak of the pandemic, ssAS patients who were previously accepted for SAVR were being reconsidered for TAVI. In a pandemic setting, TAVI has some unique organisational advantages over SAVR such as reduced resourcing needs. However, patients should be risk stratified to ensure that the risk of exposure to COVID-19 is balanced with a definitive need to treat their ssAS, allowing those with poor short-term or intermediate-term outcomes to be treated.16


References

  1. Osnabrugge RLJ, Mylotte D, Head SJ, et al. Aortic Stenosis in the Elderly: Disease Prevalence and Number of Candidates for Transcatheter Aortic Valve Replacement: A Meta-Analysis and Modeling Study. J Am Coll Cardiol. 2013;62:1002-1012.
  2. d’Arcy J, et al. Large-scale community echocardiographic screening reveals major burden of undiagnosed valvular heart disease in older people: the OxVALVE Population Cohort Study. Eur Heart J 2016;37:3515–22.  
  3. Nkomo V, et al. Burden of valvular heart disease: a population-based study. Lancet 2006;368:1005–11.  
  4. Yazdanyar A, et al. The burden of cardiovascular disease in the elderly: Morbidity, Mortality, and Costs. Clin Geriatr Med. 2009;25:563–vii. Doi:10.1016/j.cger.2009.07.007. 
  5. Spaccarotella C, et al. Pathophysiology of Aortic Stenosis and Approach to Treatment With Percutaneous Valve Implantation. Circ J 2011;75:11–9.  
  6. Cribier A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation 2002;106:3006–3008.
  7. Cahill TJ, et al. Transcatheter aortic valve implantation: current status and future perspectives. Eur Heart J. 2018;39:2625-34
  8. Leon, MB, et al. Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery. N Engl J Med 2010;363:1597–1607.
  9. Smith CR, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:2187–98. 
  10. Leon MB, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609–20.  
  11. Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patientsN Engl J Med 2019;380:1695–705.  
  12. Thourani VH, et al. Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk and high-risk patients. Ann Thoracic Surg 2015;99:55-61.
  13. Thourani VH, et al. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet 2016;2218–25 
  14. Blackman DJ, et al. Long-Term Durability of Transcatheter Aortic Valve Prostheses. J Am Coll Cardiol. 2019;73:537-45
  15. Durko AP, et al. Annual number of candidates for transcatheter aortic valve implantation per country: current estimates and future projectionsEur Heart J 2018;0:1–8. 
  16. Harky A, et al. COVID-19 and its implications on patient selection for TAVI and SAVR: are we heading into a new era. Available from: https://onlinelibrary.wiley.com/doi/10.1111/jocs.15181.

© 2021 Edwards Lifesciences Corporation. All rights reserved. PP–EU-1965 v1.0