Temporal Trends and Drivers of Heart Team Utilization in Transcatheter Aortic Valve Replacement: A Population‐Based Study in Ontario, Canada

Abstract

Background The multidisciplinary Heart Team (HT) is recommended for management decisions for transcatheter aortic valve replacement (TAVR) candidates, and during TAVR procedures. Empiric evidence to support these recommendations is limited. We aimed to explore temporal trends, drivers, and outcomes associated with HT utilization.
Methods and Results TAVR candidates were identified in Ontario, Canada, from April 1, 2012 to March 31, 2019. The HT was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period. The procedural team was defined as a billing code during the TAVR procedure. Hierarchical logistical models were used to determine the drivers of HT. Median odds ratios were calculated to quantify the degree of variation among hospitals. Of 10 412 patients referred for TAVR consideration, 5489 (52.7%) patients underwent a HT during the referral period, with substantial range between hospitals (median odds ratio of 1.78). Utilization of a HT for TAVR referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVR program size, were found associated with lower HT utilization. In TAVR procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals.
Conclusions There has been substantial decline in HT utilization for TAVR candidates over time. In addition, maturity of TAVR programs was associated with lower HT utilization.

Keywords: aortic stenosis; Heart Team; transcatheter aortic valve replacement.

Nonstandard Abbreviations and Acronyms

• AS
  aortic stenosis
• CIHI‐DAD
  the Canadian Institute for Health Information Discharge Abstract Database
• HT
  Heart Team
• ICES
  Institute for Clinical Evaluative Sciences
• MOHLTC
  Ministry of Health and Long‐Term Care
• MOR
  median odds ratio
• OHIP
  Ontario Health Insurance Plan
• SAVR
  surgical aortic valve replacement
• STROBE
  Strengthening the Reporting of Observational Studies in Epidemiology
• TAVR
  transcatheter aortic valve replacement