Service Provisions:
For context, our centre serves as a tertiary cardiac centre for 1.3 million people, over 1.26 Km2. Between 6-64% of this population identify as Aboriginal or Torre Strait Islander (ATSI), depending on regional variation. Consequently 20% of cardiac surgery preformed in our centre, is performed on ATSI people.(5) Hence, introduction of a TAVI service in our centre compared to more metropolitan centres must adapt to accommodate the geographic and demographic challenges of remote Australia.
At our centre TAVI is offered only to those deemed to be surgically high-risk or prohibitively high-risk. Objectively quantified by the Society of Thoracic Surgeons Risk Score (STS Score), where patients scoring equal to or greater than ten percent were deemed high risk. Patients may also be offered based on the individual case assessment by treating surgeon or cardiologist.
Also unique to our service model; the TAVI program is jointly run by Cardiothoracic Surgery (CTS) and Cardiology, were all cases are managed under a shared care pathway and all procedures are performed with dual proceduralist from each respective specialty.
Below is a synopsis of the current peri-operative assessment for all TAVI Candidates used in our centre:
Clinical Assessments by: (through local, outreach and telehealth clinics)
Investigations/Diagnostic Imaging:
On completion of the above the patients are then presented in the High-Risk Valve Multi-disciplinary team (MDT) meeting. This team consists of a cardiothoracic surgeon, interventional cardiologist, diagnostic imaging cardiologist, general physician/geriatrician and Cardiac Anaesthetist. This meeting formally reviews all the aforementioned investigations, discusses the suitability for sAVR, TAVI or medical management and defines ceilings of care intra and perioperatively.
Procedural access is also decided within the MDT meeting, using a 3D reconstruction of the vascular and aortic anatomy using 3mensio(PIE medical Imaging). The involvement of CTS in the TAVI program implies that in addition to transfemoral and subclavian access, direct aortic access TAVI may be utilised via hemi-stermotomy or thoracotomy.
High-risk Valve MDT meetings are held on a monthly cycle and occur one week prior to the TAVI procedural list. An intensive care physician may be involved in the MDT meeting and peri-operative assessment if the case necessitates Intensive Care Unit (ICU) admission.
Following the TAVI, patients will be admitted to either the Coronary Care Unity (CCU) or ICU.
Day one post-procedurally, all subjects undergo an echocardiogram to define their valvular gradients and Paravalvular leak. This is repeated in the outpatient department at six weeks, and one-year.
All the peri-operative data is recorded in a local database and uploaded to the Australasian Cardiac Outcome Registry (ACOR). The unit and both its cardiac surgeon and cardiologist proceduralists have been accredited with ACOR and the TAVI Committee for independent practice since April 2020.