title: Transcatheter aortic valve implantation: recommendations for practice based on a multidisciplinary review including cost-effectiveness and ethical and organizational issues.
abstract: Transcatheter aortic valve implantation (TAVI) is a relatively new technology for the treatment of severe and symptomatic aortic valve stenosis. TAVI offers an alternative therapy for patients unable to be treated surgically because of contraindications or severe comorbidities. It is being rapidly dispersed in Canada, as it is worldwide. The objective of this article is to present our recommendations for the use of TAVI, based on a multidisciplinary evaluation of recently published evidence. We systematically searched and summarized published data (2008-2011) on benefits, risks, and cost-effectiveness of TAVI. We also examined ethical issues and organizational aspects of delivering the intervention. We discussed the soundness and applicability of our recommendations with clinical experts active in the field. The published TAVI results for high-risk and/or inoperable patients are promising in terms of survival, function, quality of life, and cost-effectiveness, although we noted large variability in the survival rates at 1 year and in the frequency of important adverse outcomes such as stroke. Until more data from randomized controlled trials and registries become available, prudence and discernment are necessary in the choice of patients most likely to benefit. Patients need to be well-informed about gaps in the evidence base. Our recommendations support the use of TAVI in the context of strict conditions with respect to patient eligibility, the patient selection process, organizational requirements, and the tracking of patient outcomes with a mandatory registry.
authors.affiliation: Institut national d'excellence en santé et en services sociaux, Montréal, Québec, Canada. lucy.boothroyd@inesss.qc.ca
authors.forename: Lucy J
authors.initials: LJ
authors.lastname: Boothroyd
authors.forename: Marco
authors.initials: M
authors.lastname: Spaziano
authors.forename: Jason R
authors.initials: JR
authors.lastname: Guertin
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Lambert
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
authors.forename: Nicolas
authors.initials: N
authors.lastname: Noiseux
authors.forename: Michel
authors.initials: M
authors.lastname: Nguyen
authors.forename: Éric
authors.initials: É
authors.lastname: Dumont
authors.forename: Michel
authors.initials: M
authors.lastname: Carrier
authors.forename: Benoit
authors.initials: B
authors.lastname: de Varennes
authors.forename: Reda
authors.initials: R
authors.lastname: Ibrahim
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Martucci
authors.forename: Yongling
authors.initials: Y
authors.lastname: Xiao
authors.forename: Jean E
authors.initials: JE
authors.lastname: Morin
authors.forename: Peter
authors.initials: P
authors.lastname: Bogaty
mesh_terms: D001024:Aortic Valve Stenosis / Q000601:surgery*; D006328:Cardiac Catheterization / Q000191:economics / Q000941:ethics / Q000379:methods; D003362:Cost-Benefit Analysis; D019918:Heart Valve Prosthesis Implantation / Q000191:economics / Q000941:ethics / Q000379:methods; D006801:Humans; D017410:Practice Guidelines as Topic