10 | HOSPITAL HEALTHCARE EUROPE | 2022

Luis Nombela- Franco Interventional cardiologist from the Hospital Clínico San Carlos , Madrid , describes how the use of TAVI has evolved in his institution

About the institution Dr Nombela-Franco is the coordinator of structural heart interventions at his centre in Madrid . The first TAVI was performed at the centre in 2007 .

Why and when was TAVI introduced at your centre ? Dr Nombela-Franco performed his first TAVI procedure back in 2011 . Like most centres , he described how initially TAVI was introduced due to the higher number of patients who were either inoperable or deemed to be at high risk . As he explained , “ we were doing TAVI on high-risk or inoperable patients , moving on to intermediate risk patients .” He added that TAVI was originally undertaken on “ octogenarians and some nonagenarians , and our mean age at that time was around 84 or 85 .” He described how today his centre performs around “ 160 – 170 TAVI procedures per year and in a typical week around three to four .”

What are your perceptions of how TAVI affects patient outcomes ? Dr Nombela-Franco described how with evidence from registries and his own experience , it is known that patients have a much faster recovery after TAVI . He mentioned how typically a surgical patient might have to stay in the hospital for around 7 – 8 days whereas after TAVI , “ you can discharge a patient after 3 days ”. As the centre gained more experience with the procedure , complication rates reduced and are now much lower . He feels that a further advantage of TAVI is that patients have fewer peri-procedural complications compared with surgery .

How has TAVI impacted on hospital efficiencies ? Dr Nombela-Franco felt that there are currently limited cost-effectiveness studies to provide robust evidence evidence for the benefits of TAVI over surgery . Moreover , despite the higher costs of TAVI prosthetic valves compared with their surgical counterparts , there were still costadvantages to a hospital in performing TAVI . For instance , he noted how with TAVI “ patients can be discharged earlier , their stay in coronary or intensive care is shorter and that some patients don ’ t even require ICU or CCU stays , and so I think overall they have fewer complications and that TAVI is a cost-effective technique .” He added that more TAVI procedures can be performed per day than surgical procedures , thereby increasing patient throughput , which results in benefits to cost-effectiveness .

Have there been any barriers to the adoption of TAVI at your centre ? Dr Nombela-Franco mentioned how in the early days of TAVI , the hospital had raised concerns over the cost of the procedure but that this is no longer the case .

During the pandemic , what were the major challenges ? Dr Nombela-Franco described how during the first wave of the pandemic , his centre was closed for about 6 weeks and was not allowed to admit any patients from home because of the risks due to COVID-19 . However , once the centre re-opened and started performing TAVI , although the pace was initially slower than usual , he explained the centre “ ended up doing the same or slightly more procedures than the year before [ the pandemic ], catching up swiftly during the summer .”

Looking to the future Dr Nombela-Franco believes that some work needs to be done for the conduction disturbances that can arise after a TAVI procedure . He felt that a better understanding of the conduction system in the heart would be beneficial . He noted that now “ we are implanting the valve in a higher position than ever and I think we are going to achieve better numbers but some patients will still have some complications , so refinements in implantation technique or a better understanding of the conduction system [ would help ].”

He no longer believes that bleeding is a problem with the technique and that while it will still might happen for some patients , he does not think that the incidence can be reduced any further but remarked upon how the bleeding rate is much higher with surgery .

Although mortality is the most serious outcome from TAVI , Dr Nombela-Franco said that at his centre last year , there were no deaths associated with TAVI and that the incidence should be less than 1 %, adding that “ bleeding , coronary obstructive or stroke , perforation , tamponade and rupture are quite rare complications .”

Although Dr Nombela-Franco thinks that his centre can do more TAVIs , a current problem is staff shortages with both radiologists and anaesthesiologists . As he explained , the “ radiologists do not do all the CTs we would like for