14 | HOSPITAL HEALTHCARE EUROPE | 2022

Nicolas Van Mieghem is an interventional cardiologist and medical director at the Thoraxcenter , Erasmus Medical Center , The Netherlands . He shares his experience of TAVI and how the procedure is now gaining more awareness with the public

About the institution Prof Van Mieghem described how Erasmus is a busy tertiary care hospital that performs about 350 TAVI cases per year , around 50 mitral clips and perhaps a further 20 – 30 complex structural heart interventions , including a congenital structural heart programme . With such a large workload , he says that there are “ about 38 cardiologists in the department , 7 interventional cardiologists and 3 cardiologists who do structural interventions ”. He explained that while the department can perform up to five TAVI procedures per day , typically the department would carry out three , although this very much depends upon the caseload .

Why and when was TAVI introduced at the Erasmus hospital ? Prof Van Mieghem depicted how patients with symptomatic aortic stenosis experience a huge decrease in their quality of life , adding that , “ once symptoms kick in , mortality is between 25 and 50 % within the first year ”. In the past , surgical valve replacement was the only treatment option but many patients were being declined therapy despite a guideline recommended indication for aortic valve replacement and the main reason for declining the procedure was the patient ’ s age or comorbidities . He noted , “ about 20 years ago , this figure was around 30 % of all cases and served as a driver for a less-invasive therapy ”.

His department performed its first TAVI back in 2004 ( by Professor Peter de Jaegere ) and the number of cases has increased steadily every year so that TAVI has now surpassed the level of surgical interventions . Today , the proportion of patients declined a TAVI is low , at around 5 %– 10 % and largely due to instances of dementia , cancer or other diseases that would mitigate their long-term life expectancy . As he clarified , “ if we estimate that the life expectancy is less than one year , we won ’ t proceed with a valve replacement ”.

How has the use of TAVI impacted on patient outcomes ? Perhaps the most noticeable impact of TAVI , he feels , is the rapid improvement in patient symptoms after the procedure . As he says , “ in the past , patients at high operative risk may survive their surgery but then they may not survive their recovery period ”. In contrast , with TAVI , “ if everything goes well , which fortunately happens in the majority of cases , then these patients are on their way home on day two and they immediately feel better ”. He discussed how a typical TAVI procedure takes around “ 45 minutes and is performed under local anaesthesia and only uses two catheters ”. While there are different TAVI devices , Professor Van Mieghem felt that no “ one valve fits all ” and that he and his colleagues have moved towards a more patient-tailored valve selection process that involves a patient risk assessment , considering co-morbidities , age , and the need for other surgical procedures , etc ..

How has TAVI impacted on hospital efficiencies ? Prof Van Mieghem believes the impact on hospital efficiencies has been enormous , as he says , “ our surgical team can perform two procedures in one day , whereas we can go up to five [ TAVIs ]”. Without the need for a post-operative intensive care stay and additional anaesthesia , the turnover of the patients is much faster and there are a smaller number of physicians involved with each patient .

Why do you think there has been an increase in the use of TAVI ? Prof Van Mieghem thought that the increased number of TAVI procedures was driven by both a greater awareness of the less-invasive nature of the procedure coupled with a greater level of referral by general practitioners and general cardiologists . He felt that perhaps ten years ago , a clinician might think that for someone with aortic stenosis , “ this patient is too old , I ’ m not going to refer them , whereas now they refer patients and can see the immediate benefit .” As he continued , “ in the past , the GP became used to a 3- or 6-month recovery time but can now see the patient moving around better than they had been in the last two years ”.

Do you feel there any barriers to adopting TAVI ? Initially , Prof Van Mieghem was acutely aware of the steep learning curve for interventional cardiologists starting to perform TAVI and it is virtually impossible to just suddenly start performing the technique . Another important barrier is that , generally speaking , “ less than 5 % of patients are truly inoperable .” Thus , for a new centre performing TAVI , although the initial cohort would be low-risk surgery patients , he felt that they were likely to “ see more complications in terms of vascular access , or pacemakers than experienced sites ”, simply because the team lacks experience . Moreover , he thought that at the present time ,