title: Transcatheter aortic valve replacement in Europe: adoption trends and factors influencing device utilization.
abstract: OBJECTIVE
  The authors sought to examine the adoption of transcatheter aortic valve replacement (TAVR) in Western Europe and investigate factors that may influence the heterogeneous use of this therapy.
  
  
  BACKGROUND
  Since its commercialization in 2007, the number of TAVR procedures has grown exponentially.
  
  
  METHODS
  The adoption of TAVR was investigated in 11 European countries: Germany, France, Italy, United Kingdom, Spain, the Netherlands, Switzerland, Belgium, Portugal, Denmark, and Ireland. Data were collected from 2 sources: 1) lead physicians submitted nation-specific registry data; and 2) an implantation-based TAVR market tracker. Economic indexes such as healthcare expenditure per capita, sources of healthcare funding, and reimbursement strategies were correlated to TAVR use. Furthermore, we assessed the extent to which TAVR has penetrated its potential patient population.
  
  
  RESULTS
  Between 2007 and 2011, 34,317 patients underwent TAVR. Considerable variation in TAVR use existed across nations. In 2011, the number of TAVR implants per million individuals ranged from 6.1 in Portugal to 88.7 in Germany (33 ± 25). The annual number of TAVR implants performed per center across nations also varied widely (range 10 to 89). The weighted average TAVR penetration rate was low: 17.9%. Significant correlation was found between TAVR use and healthcare spending per capita (r = 0.80; p = 0.005). TAVR-specific reimbursement systems were associated with higher TAVR use than restricted systems (698 ± 232 vs. 213 ± 112 implants/million individuals ≥ 75 years; p = 0.002).
  
  
  CONCLUSIONS
  The authors' findings indicate that TAVR is underutilized in high and prohibitive surgical risk patients with severe aortic stenosis. National economic indexes and reimbursement strategies are closely linked with TAVR use and help explain the inequitable adoption of this therapy.
authors.affiliation: Department of Interventional Cardiology at McGill University Health Centre, Montreal, Quebec, Canada; Galway University Hospital, Galway, Ireland.
authors.forename: Darren
authors.initials: D
authors.lastname: Mylotte
authors.affiliation: Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Ruben L J
authors.initials: RLJ
authors.lastname: Osnabrugge
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.affiliation: Institut Cardiovasculaire Paris Sud, Massy, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Lefèvre
authors.affiliation: Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: de Jaegere
authors.affiliation: University Hospital Basel, Basel, Switzerland.
authors.forename: Raban
authors.initials: R
authors.lastname: Jeger
authors.affiliation: Department of Cardiology, Bern University Hospital, Bern, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Wenaweser
authors.affiliation: Department of Cardiac Surgery, San Raffaele Hospital, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.affiliation: Royal Brompton Hospital and on behalf of NICOR, London, United Kingdom.
authors.forename: Neil
authors.initials: N
authors.lastname: Moat
authors.affiliation: Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Søndergaard
authors.affiliation: Department of Cardiology, University Hospital Antwerp, Wilrijk, Belgium.
authors.forename: Johan
authors.initials: J
authors.lastname: Bosmans
authors.affiliation: Hospital de Santa Cruz, Lisbon, and on behalf of VAP APIC-SPC, Portugal.
authors.forename: Rui C
authors.initials: RC
authors.lastname: Teles
authors.affiliation: Department of Interventional Cardiology at McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Martucci
authors.affiliation: Heart Centre, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Manoharan
authors.affiliation: Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain.
authors.forename: Eulogio
authors.initials: E
authors.lastname: Garcia
authors.affiliation: Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Nicolas M
authors.initials: NM
authors.lastname: Van Mieghem
authors.affiliation: Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: A Pieter
authors.initials: AP
authors.lastname: Kappetein
authors.affiliation: Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
authors.affiliation: Department of Cardiovascular Surgery, German Heart Center, Munich, Germany.
authors.forename: Ruediger
authors.initials: R
authors.lastname: Lange
authors.affiliation: Department of Interventional Cardiology at McGill University Health Centre, Montreal, Quebec, Canada; Department of Cardiovascular Surgery, German Heart Center, Munich, Germany. Electronic address: nicolopiazza@me.com.
authors.forename: Nicolo
authors.initials: N
authors.lastname: Piazza
mesh_terms: D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D006328:Cardiac Catheterization / Q000706:statistics & numerical data* / Q000639:trends; D005060:Europe / Q000453:epidemiology; D019918:Heart Valve Prosthesis Implantation / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D012042:Registries