title: Outcomes of transfemoral transcatheter aortic valve implantation at hospitals with and without on-site cardiac surgery department: insights from the prospective German aortic valve replacement quality assurance registry (AQUA) in 17 919 patients.
abstract: Performing transcatheter aortic valve implantation (TAVI) at hospitals with only cardiology department but no cardiac surgery (CS) on-site is at great odds with current Guidelines.
  
  
  
  We analysed data from the official, prospective German Quality Assurance Registry on Aortic Valve Replacement to compare characteristics and in-hospital outcomes of patients undergoing transfemoral TAVI at hospitals with (n = 75) and without CS departments (n = 22). An interdisciplinary Heart Team was established at all centres (internal staff physicians at hospitals with on-site CS; in-house cardiologists and visiting cardiac surgical teams from collaborating hospitals at non-CS hospitals). In 2013 and 2014, 17 919 patients (81.2 ± 6.1 years, 55% females, German aortic valve (GAV) score 2.0 5.6 ± 5.8%, logistic EuroSCORE I 21.1 ± 15.4%) underwent transfemoral TAVI in Germany: 1332 (7.4%) at hospitals without on-site CS department. Patients in non-CS hospitals were older (82.1 ± 5.8 vs. 81.1 ± 6.1 years, P < 0.001), with more frequent co-morbidities. Predicted mortality risks per GAV-score 2.0 (6.1 + 5.5 vs. 5.5 ± 5.9%, P < 0.001) and logEuroSCORE I (23.2 ± 15.8 vs. 21.0 ± 15.4%, P < 0.001) were higher in patients at non-CS sites. Complications, including strokes (2.6 vs. 2.3%, P = 0.452) and in-hospital mortality (3.8 vs. 4.2%, P = 0.396), were similar in both groups. Matched-pair analysis of 555 patients in each group with identical GAV-score confirmed similar rates of intraprocedural complications (9.2 vs. 10.3%, P = 0.543), strokes (3.2% for both groups, P = 1.00), and in-hospital mortality (1.8 vs. 2.9%, P = 0.234).
  
  
  
  Although patients undergoing TAVI at hospitals without on-site CS department were older and at higher predicted perioperative death risk, major complications, and in-hospital mortality were not statistically different, suggesting the feasibility and safety of Heart Team-based TAVI at non-CS sites. These findings need confirmation in future randomized study.
authors.affiliation: Cardioangiological Center Bethanien (CCB) and AGAPLESION Bethanien Hospital, Frankfurt, Germany h.eggebrecht@ccb.de.
authors.forename: Holger
authors.initials: H
authors.lastname: Eggebrecht
authors.affiliation: ProMedCon GmbH, Ebenhausen, Germany.
authors.forename: Maike
authors.initials: M
authors.lastname: Bestehorn
authors.affiliation: Medical Clinic I, Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Neuss, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Haude
authors.affiliation: Cardioangiological Center Bethanien (CCB) and AGAPLESION Bethanien Hospital, Frankfurt, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Schmermund
authors.affiliation: Technical University of Dresden, Dresden, Germany.
authors.forename: Kurt
authors.initials: K
authors.lastname: Bestehorn
authors.affiliation: Cardioangiological Center Bethanien (CCB) and AGAPLESION Bethanien Hospital, Frankfurt, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Voigtländer
authors.affiliation: Department of Cardiology, Asklepios Hospital St Georg, Hamburg, Germany.
authors.forename: Karl-Heinz
authors.initials: KH
authors.lastname: Kuck
authors.affiliation: Duke Clinical Research Institute and Duke University Medical Center, Durham, NC, USA.
authors.forename: Rajendra H
authors.initials: RH
authors.lastname: Mehta
mesh_terms: D000369:Aged, 80 and over; D001021:Aortic Valve; D001024:Aortic Valve Stenosis; D006328:Cardiac Catheterization; D005260:Female; D005858:Germany; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012042:Registries; D065467:Transcatheter Aortic Valve Replacement; D016896:Treatment Outcome
keywords: Aortic stenosis; Complications; Conversion; Surgery; TAVI; TAVR