title: Regional Systems of Care to Optimize Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.
abstract: OBJECTIVE
  This study sought to describe the development of a multicenter, transcatheter aortic valve replacement program and regional systems of care intended to optimize coordinated, efficient, and appropriate delivery of this new therapy.
  
  
  BACKGROUND
  Transcatheter aortic valve replacement (TAVR) has become an accepted treatment option for patients with severe aortic stenosis who are at high surgical risk. Regional systems of care have led to improvements in outcomes for patients undergoing intervention for myocardial infarction, cardiac arrest, and stroke. We implemented a regional system of care for patients undergoing TAVR in British Columbia, Canada.
  
  
  METHODS
  We describe a prospective observational cohort of 583 patients who underwent TAVR in British Columbia between 2012 and 2014. Regionalization of TAVR care in British Columbia refers to a centrally coordinated, funded, and evaluated program led by a medical director and a multidisciplinary advisory group that oversees planning, access to care, and quality of outcomes at the 4 provincial sites. Risk-stratified case selection for transfemoral TAVR is performed by heart teams at each site on the basis of consensus provincial indications. Referrals for lower volume and more complicated TAVR, including nontransfemoral access and valve-in-valve procedures, are concentrated at a single site. In-hospital and 30-day outcomes are reported.
  
  
  RESULTS
  The median age was 83 years (interquartile range [IQR]: 78 to 87 years) and median STS score was 6% (IQR: 4% to 8%). Transfemoral access was performed in 499 (85.6%) cases and nontransfemoral in 84 (14.4%). Transcatheter valve-in-valve procedures in for failed bioprosthetic valves were performed in 43 patients (7.4%). A balloon-expandable valve was inserted in 386 (66.2%) and a self-expanding valve in 189 (32.4%). All-cause 30-day mortality was 3.5%. All-cause in-hospital mortality and disabling stroke occurred in 3.1% and 1.9%, respectively. Median length of stay was 3 days (IQR: 3 to 6 days), with 92.8% of patients discharged directly home.
  
  
  CONCLUSIONS
  This experience demonstrates the potential benefits of a regional system of care for TAVR. Excellent outcomes were demonstrated: most patients had short in-hospital stays and were discharged directly home.
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; Division of Cardiology, Alfred Hospital, Western Health, Baker IDI Heart and Diabetes Institute, Melbourne Australia.
authors.forename: Dion
authors.initials: D
authors.lastname: Stub
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Cardiac Services BC, Vancouver, British Columbia, Canada.
authors.forename: Sandra
authors.initials: S
authors.lastname: Lauck
authors.affiliation: BC Centre for Improved Cardiovascular Health, Vancouver, British Columbia, Canada.
authors.forename: May
authors.initials: M
authors.lastname: Lee
authors.affiliation: BC Centre for Improved Cardiovascular Health, Vancouver, British Columbia, Canada.
authors.forename: Min
authors.initials: M
authors.lastname: Gao
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada; BC Centre for Improved Cardiovascular Health, Vancouver, British Columbia, Canada.
authors.forename: Karin
authors.initials: K
authors.lastname: Humphries
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada; Divisions of Cardiology and Cardiac Surgery, Royal Columbian Hospital, Vancouver, British Columbia, Canada.
authors.forename: Albert
authors.initials: A
authors.lastname: Chan
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Anson
authors.initials: A
authors.lastname: Cheung
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Divisions of Cardiology and Cardiac Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Cook
authors.affiliation: Division of Cardiology, Royal Jubilee Hospital, Victoria, British Columbia, Canada.
authors.forename: Anthony
authors.initials: A
authors.lastname: Della Siega
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.affiliation: Divisions of Cardiology and Cardiac Surgery, Royal Columbian Hospital, Vancouver, British Columbia, Canada.
authors.forename: Jay
authors.initials: J
authors.lastname: Charania
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.affiliation: Divisions of Cardiology and Cardiac Surgery, Royal Columbian Hospital, Vancouver, British Columbia, Canada.
authors.forename: Tim
authors.initials: T
authors.lastname: Latham
authors.affiliation: Cardiac Services BC, Vancouver, British Columbia, Canada.
authors.forename: Jopie
authors.initials: J
authors.lastname: Polderman
authors.affiliation: Division of Cardiology, Royal Jubilee Hospital, Victoria, British Columbia, Canada.
authors.forename: Simon
authors.initials: S
authors.lastname: Robinson
authors.affiliation: Divisions of Cardiology and Cardiac Surgery, Royal Columbian Hospital, Vancouver, British Columbia, Canada.
authors.forename: Daniel
authors.initials: D
authors.lastname: Wong
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Thompson
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Divisions of Cardiology and Cardiac Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Wood
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jian
authors.initials: J
authors.lastname: Ye
authors.affiliation: Centre for Heart Valve Innovation, St. Paul's Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Cardiac Services BC, Vancouver, British Columbia, Canada. Electronic address: john.webb@vch.ca.
authors.forename: John
authors.initials: J
authors.lastname: Webb
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D001955:British Columbia; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D006302:Health Services Research; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D017146:Models, Organizational; D010348:Patient Care Team / Q000458:organization & administration; D018579:Patient Selection; D017064:Process Assessment, Health Care; D015397:Program Evaluation; D011446:Prospective Studies; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012017:Referral and Consultation / Q000458:organization & administration; D012040:Regional Health Planning / Q000458:organization & administration*; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic stenosis; transcatheter aortic valve replacement