More experienced TAVI centres “less likely to use heart team approach”

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TAVI

Assessment of patients by both interventional cardiologists and cardiac surgeons prior to transcatheter aortic valve intervention (TAVI)—known as the heart team approach—appears to be declining, particularly in centres with more mature TAVI programmes. This is according to a study of temporal trends of heart team utilisation in TAVI referrals and treatment allocation in Ontario, Canada from 2012–2019, findings from which were published online in the Journal of the American Heart Association (JAHA).  

Study authors Gil Marcus, Harindra C Wijeysundera (Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada) et al speculate that the findings may suggest that more mature TAVI programmes have more comfort in determining patient eligibility for TAVI without requiring a full heart team approach on all patients.

Marcus, Wijeysundera et al  begin by noting that TAVI has evolved to become the standard of care, or a reasonable alternative, for patients with severe aortic stenosis (AS) across the entire spectrum of patient risk.

Over the course of this evolution, the need for multidisciplinary care has gained recognition. The heart team concept—a collaborative approach to determine setting treatment strategies and to ensure multidisciplinary participation in procedures—has emerged as an important principal endorsed by a number of professional societies.

Using data from the CorHealth Ontario registry, the study team looked at AS patients referred for consideration for TAVI at 11 tertiary cardiac hospitals with onsite cardiac surgery, from the time of referral until they were off-listed.

The heart team was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period, while the procedural team was defined as having a billing code during the TAVI procedure. Hierarchical logistical models were used to determine the drivers of heart team utilisation, and median odds ratios (ORs) were calculated to quantify the degree of variation among hospitals.

According to the study’s authors, of 10,412 patients referred for TAVI consideration, 5,489 (52.7%) patients were referred via the heart team, with a substantial range between hospitals (median OR, 1.78). Further to this, Marcus, Wijeysundera et al found that utilisation of the heart team for TAVI referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVI programme size, were found to be associated with lower heart team utilisation. However, despite a decline in heart team utilisation during referrals, the study team found that during the TAVI procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals.

Discussing the findings, the authors write that factors that seem to reflect programmatic maturity, such as higher volumes of TAVI completed, were associated with a lower heart team utilisation.

They add: “Our findings may reflect that mature programmes have more comfort in determining patient eligibility for TAVI without requiring a full heart team approach on all patients, given their experience in understanding which patients are most appropriate for each procedure. Indeed, reassuringly, despite the observed decline in heart team utilisation in TAVI candidates, we did not find evidence that treatment allocation was influenced by this change.”

The authors note that the study has several limitations, notably that the definition of a heart team was based on encounters with a cardiologist and a cardiac surgeon within a timeframe, not necessarily on the same day. Secondly, an important part of the data source, the billing done by the cardiologist and by the cardiac surgeon, is subject to under‐reporting, they add. The dataset also lacked granular information that precluded the calculation of risk scores such as the Euroscore or Society for Thoracic Surgeons (STS), while the analysis was done on a cohort of patients who were referred for TAVI consideration and may not be fully generalisable to all AS patients, for which the guidelines recommend the heart team approach.

Further study is needed to understand the implications of these observations so as to better inform best practice recommendations, the authors add.


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