Eric Durand

Background: Transcatheter options are increasingly available for the treatment of valvular heart disease. The role of the clinical valve co-ordinator is ideally positioned to improve access to care, quality of outcomes, and patient experiences, contribute to efficiencies, and support the growing number of heart valve centres. International societies and guidelines recommend the inclusion of the clinical valve co-ordinator in multidisciplinary Heart Teams to support patients, contribute unique expertise to team-based care, and help programmes expand access to care. The role of the clinical valve co-ordinator is unevenly adopted in Europe. Aims: To provide guidance on developing, implementing, and sustaining the role of clinical valve co-ordinators to support patients and programmes. Methods and results: We outline a comprehensive framework of the competencies and professional development aligned with the needs of patients with aortic, mitral, and tricuspid disease, discuss requirements for infrastructure and successful organizational integration in valvular heart disease teams and programmes, and propose preliminary indicators to measure role impact and address the current gap in evidence to guide role development across diverse regions. The clinical valve co-ordinator plays a vital role as a central member of the multidisciplinary team to support the care requirements of people with complex valvular heart disease in the rapidly evolving clinical context of treatment options and management strategies. Conclusion: The document provides a roadmap for the development, implementation, and evaluation of a pan-European initiative to improve the delivery of valvular heart disease services and optimize the experience of care of patients and their family.

Background: Benchmark best practices have been shown to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI), but the impact in diverse health systems is unknown. Aims: We evaluated the impact of Benchmark best practices implementation in Germany, Austria, France, Spain, and Italy. Methods: International, multicentre registry of severe symptomatic aortic stenosis (AS) patients undergoing TAVI with a balloon-expandable valve, before and after Benchmark best practices implementation. Objectives were to reduce overall and intensive care unit (ICU) length of stay (LoS), and to document 30-day safety. Results: A total of 890 patients were analysed in France, 454 in Spain, 362 in Germany, 300 in Italy, and 176 in Austria. Patients had the highest surgical risk in Germany (EuroSCORE II 6.8 ± 7.3%) and lowest in Spain (3.8 ± 2.6%). Austrian patients reported higher rates of prior myocardial infarction, severe pulmonary hypertension, and aortic valve-related symptoms at baseline. After the implementation of Benchmark best practices, the median hospital LoS was significantly reduced in France (5 vs. 3 days, p < 0.001), Spain (6 vs. 4, p < 0.001), Germany (9 vs. 6, p < 0.001), and Italy (7 vs. 5, p < 0.001); reductions in median ICU LoS were reported in France (1.1 vs. 0 days, p < 0.001), Spain (1.9 vs. 1, p < 0.001), and Germany (1 vs. 0.9, p = 0.004). Across all countries, 30-day safety outcomes were uncompromised and reduced rates of major vascular complications rates were observed in Germany (5.9 vs. 0.0%, p < 0.001). Conclusion: The implementation of Benchmark best practices in diverse European healthcare systems resulted in reduced hospital and ICU LoS without compromising patient safety. Trial registration: ClinicalTrials.gov NCT04579445, September 28th, 2020

Introduction: Conductive disturbances requiring permanent pacemaker (PPM) implantation remain a major concern after transcatheter aortic valve implantation (TAVI). Aims: To assess the impact of aortic valve calcium score (AVCS) on conductive disturbances requiring PPM after TAVI. Methods: All patients who underwent TAVI with accessible AVCS from the preprocedural CT scan report were included in this retrospective single-centre study. The primary endpoint was the occurrence of a conductive disturbance requiring PPM at 30 days. The association between PPM and AVCS, with its incremental prognostic value, was analysed using multivariable logistic regression, receiver operating characteristic curve analysis and likelihood ratio (LR) test. Results: We included 761 patients of which 125 (16%) required PPM at 30 days. AVCS score was significantly higher in patients requiring PPM (3788 (2487–5218) vs 3050 (2043–4367) AU, p<0.001). Using multivariable analysis, preprocedural right bundle branch block (RBBB) (OR 6.61, 95% CI 3.82 to 11.5, p4510 AU (OR 1.83, 95% CI 1.04 to 3.20, p=0.035) were independently associated with PPM. AVCS had an incremental discriminative value (C-index 0.79 vs 0.77, LR test p=0.036) over and above traditional PPM risk factors. An algorithm was proposed based on the initial presence of RBBB, AVCS and the type of implanted valve. Conclusion: Even if RBBB remained the strongest predictor of PPM post-TAVI, this study suggests that a high AVCS may help identifying patients at increased risk of PPM after TAVI, especially among those without pre-existing RBBB.

When PCI should be performed in patients undergoing TAVI

There is significant potential to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the effect of implementing BENCHMARK best practices on the efficiency and safety of TAVI in 28 sites in 7 European countries. This was a study of patients with severe symptomatic aortic stenosis (AS) undergoing TAVI with balloon-expandable valves before and after implementation of BENCHMARK best practices. Principal objectives were to reduce hospital length of stay (LoS) and duration of intensive care stay. Secondary objective was to document patient safety. Between January 2020 and March 2023, 897 patients were documented prior to and 1491 patients after the implementation of BENCHMARK practices. Patient characteristics were consistent with a known older TAVI population and only minor differences. Mean LoS was reduced from 7.7 ± 7.0 to 5.8 ± 5.6 days (median 6 vs. 4 days; P < .001). Duration of intensive care was reduced from 1.8 to 1.3 days (median 1.1 vs. 0.9 days; P < .001). Adoption of peri-procedure best practices led to increased use of local anaesthesia (96.1% vs. 84.3%; P < .001) and decreased procedure (median 47 vs. 60 min; P < .001) and intervention times (85 vs. 95 min; P < .001). Thirty-day patient safety did not appear to be compromised with no differences in all-cause mortality (0.6% in both groups combined), stroke/transient ischaemic attack (1.4%), life-threatening bleeding (1.3%), stage 2/3 acute kidney injury (0.7%), and valve-related readmission (1.2%). Broad implementation of BENCHMARK practices contributes to improving efficiency of TAVI pathway reducing LoS and costs without compromising patient safety. BENCHMARK: streamlined transcatheter aortic valve implantation (TAVI) pathway with retained safety. CCU, coronary care unit; ICU, intensive care unit; GW, general ward; IMC, intermediate care; PPM, permanent pacemaker. *Includes patients with available data on LoS only.