6 | HOSPITAL HEALTHCARE EUROPE | 2022

Sabine Bleiziffer Cardiac surgeon from the Heart and Diabetes Centre , NRW , Bad Oeynhausen , Germany describes her experience of TAVI and the role of the interdisciplinary heart team

About the institution Dr Bleiziffer works at the Heart and Diabetes centre in northern Germany . The centre performs a number of different procedures including cardiothoracic surgery , cardiology , electrophysiology , paediatric cardiology and cardiac surgery , and diabetology . The centre has over 2000 staff and is one of the largest centres in Germany , performing over 3500 surgical heart procedures each year with heart lung machines , heart failure , transplant and ventricular assist devices . While TAVI has only started in the last few years , the centre performs around 700 such procedures each year , amounting to 4 – 5 per day .

Why and when was TAVI introduced at your centre ? Dr Bleiziffer described how TAVI was adopted at the hospital in 2009 simply because the procedure was seen as a major development in cardiology . Moreover , she added how there has been a growth in the use of TAVI after the introduction of ESC guidelines in both 2017 and 2021 , which recommended that the procedure was the preferred option for eligible patients 75 years and older . This provided clinicians with much needed clarity , as Dr Bleiziffer explained , because in the past , the decision to use TAVI had been based simply on whether the patient was considered as high / intermediate / low risk .

Today , however , many more factors are included in the decision-making process such that the “ role of the interdisciplinary heart team ” is more important . The team serves to “ evalute the patient , the risk for the patient , the anatomy , femoral access , etc ” to “ decide which would be the most beneficial intervention for the patient .” Dr Bleiziffer added how a further and important consideration was whether TAVI eligible patients could be enrolled into a randomised clinical trial because as she explained , “ we don ’ t have enough data to clearly say which is the patient who benefits more or most , from one or the other procedure .” She added that the purpose of many of these trials is to compare mortality outcomes , citing the DEDICATE trial , which is designed to compare whether TAVI is non-inferior to surgical valve replacement and feels that such trials will provide a “ real world picture of TAVI in Germany with secondary endpoints looking at complications , with patients followed up to 5 years ”. Her own view is that “ the longterm durability of the protheses ( i . e ., TAVI or surgical ) is equal .”

How has TAVI impacted on patient outcomes ? The fact that TAVI requires only a local rather than a general anaesthetic is a major advantage . As Dr Bleiziffer explained , “ the procedure lasts only around 45 minutes so patients are awake after that and have the potential to recover more quickly .” She added how TAVI has had a major impact on surgical outcomes because “ all the sick patients went to TAVI so that now we have very good results for both surgery and TAVI and the number of conventional surgery procedures is reducing , so TAVI has had a huge impact on surgery .” Although , in theory , a patient could go home on the same day after their TAVI , Dr Bleiziffer mentioned that in Germany , patients have to stay a minimum number of days to ensure that the hospital receives the full reimbursement .

What about the associated hospital efficiencies ? Dr Bleiziffer clarified that over the last few years , the reimbursement for TAVI has reduced ; nevertheless , while the decision to perform either TAVI or surgery remains a clinical one , in terms of performance , there is a balance to be struck between the two procedures . Therefore , while reimbursements per patient are less for TAVI , Dr Bleiziffer said that TAVI enabled a greater throughput of patients , thereby increasing hospital income .

What were the challenges imposed by the COVID-19 pandemic ? Dr Bleiziffer revealed how an interesting observation during the pandemic in 2020 was that while many elective procedures were cancelled , her centre still undertook more TAVI procedures , particularly among the very sick with comorbidities and the more urgent cases . She added that although there was a shortage of intensive care beds during the pandemic , this factor alone did not influence their decision between TAVI and surgery .

Looking to the future – what innovations would you like to see ? Dr Bleiziffer is aware of ongoing work to try and reduce the pacemaker rates with TAVI . She added that refinement of the implantation process might enable future coronary access , noting how attempts are also underway to reduce paravalvular leakages with better materials . Although femoral access problems can occur , Dr Bleiziffer does not see this as an important issue as approximately