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Transcatheter aortic valve implantation efficiency programs: Optimised TAVI pathways

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.