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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.

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