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)
- TAVI proceduralists (Cardiac Surgeon or Cardiologist)
- Geriatrician
- Cardiac Anaesthetist
Investigations/Diagnostic Imaging:
- Basic Biochemistry
- Extended Geriatric screening
- Transthoracic Echocardiography (TTE)
- Carotid Doppler Ultrasonography
- Coronary Angiogram
- TAVI protocol Computed Tomography (CT)
- Electrocardiogram (ECG)
- Respiratory Function Testing (RFTs)
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.