Position Statement
Position statement on transcatheter aortic valve implantation in Portugal
Posição de consenso sobre válvulas aórticas percutâneas transcatéter em Portugal
Rui Campante Telesa,
, Vasco Gama Ribeirob, Lino Patrícioc, José Pedro Nevesd, Luís Vougae, José Fragataf, Manuel Almeidaa, Pedro Bragab, Duarte Cacelac, Miguel Abecasisd, Pedro Canas da Silvag, Hélder Pereirah
Corresponding author
a Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal
b Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal
c Serviço de Cardiologia, Hospital de Santa Marta, CHLC, Lisboa, Portugal
d Serviço de Cirurgia Cardiotorácica, Hospital de Santa Cruz, CHLO, Lisboa, Portugal
e Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal
f Serviço de Cirurgia Cardiotorácica, Hospital de Santa Marta, CHLC, Lisboa, Portugal
g Serviço de Cardiologia, Hospital de Santa Maria, CHLN, Lisboa, Portugal
h Associação Portuguesa de Intervenção Cardiovascular da Sociedade Portuguesa de Cardiologia, Lisboa, Portugal
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array:3 [ "entidad" => "Serviço de Cirurgia Cardiotorácica, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Serviço de Cirurgia Cardiotorácica, Hospital de Santa Marta, CHLC, Lisboa, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Maria, CHLN, Lisboa, Portugal" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Associação Portuguesa de Intervenção Cardiovascular da Sociedade Portuguesa de Cardiologia, Lisboa, Portugal" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Posição de consenso sobre válvulas aórticas percutâneas transcatéter em Portugal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Preamble</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of calcific aortic stenosis is growing due to the increase in degenerative valve disease, which affects 2.5% of people aged over 65; it is estimated that at least 32000 individuals in Portugal have the condition.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The first-line treatment is surgical aortic valve replacement (SAVR).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Outcomes are adversely affected by the presence of certain comorbidities, and so transcatheter aortic valve implantation (TAVI) was developed for patients considered unsuitable for surgery.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2012 guidelines published jointly by the European Society of Cardiology (ESC) and the European Association of Cardio-Thoracic Surgery (EACTS) assign a class I or IIa recommendation for TAVI according to clinical indications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">National data for Portugal indicate an annual rate of TAVI of seven procedures per million population, a third of the rate in Spain and the UK and a seventh of the European Union average of 45 implantations.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Current evidence on transcatheter aortic valve implantation and the situation in Portugal</span><p id="par0025" class="elsevierStylePara elsevierViewall">The PARTNER trial, the only randomized study to date, reported a reduction in overall mortality in inoperable patients (cohort B) from 51% with optimal medical therapy to 31% with TAVI at one-year follow-up.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Use of TAVI was further consolidated following publication of the second arm of the trial (cohort A), in which the percutaneous technique, via a transfemoral or transaortic approach, was compared with SAVR. Outcomes for TAVI tended to be better in terms of 30-day mortality (3.4% in the TAVI group vs. 6.5% in the SAVR group, p=0.07), but there was no significant difference in two-year mortality (33.9% TAVI vs. 35% SAVR),<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> both groups presenting significant functional improvement at two-year follow-up.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Numerous registries have been published suggesting that the efficacy and safety of TAVI are generally good when performed outside of trials. Piazza et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> published one of the first in 2008, reporting 30-day mortality of 8.0% and a combined major event rate – death, myocardial infarction and stroke – of 9.3%. Four years later, in the UK TAVI registry of 870 patients, 30-day mortality was 7.1%, but rose to 26.3% at two-year follow-up. The landmark FRANCE 2 registry, a mandatory official registry, with 3195 patients, covering all types of valve and approaches, including subclavian and transaortic, reports 30-day and one-year mortality of 9.7% and 24%, respectively.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The only registry directly comparing TAVI with SAVR is an Italian one analyzing 618 patients that used three methods of statistical adjustment, including propensity scores. The annual major event rate based on the Valve Academic Research Consortium (VARC) criteria was 11.8%, with no significant differences between the two techniques in occurrence of death, stroke or myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The impact on quality of life has been the focus of much interest since the evidence consistently shows marked improvement from one month after TAVI.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In general, the technique is used in patients who are judged inoperable or at high surgical risk due to older age, comorbidities, female gender, higher functional class, emergency operation, left ventricular dysfunction, pulmonary hypertension, coexisting coronary artery disease, or previous cardiac surgery, including for bioprosthetic valve failure.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">It should be stressed that implementation of TAVI programs has generally involved highly motivated teams with proctoring in the first 5–15 cases.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Notwithstanding the good results obtained, certain aspects give rise to concern. Various periprocedural complications can require particular attention.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> Periprosthetic regurgitation, mitral regurgitation and need for pacing appear to adversely affect long-term outcomes.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,17–19</span></a> Medium-term non-cardiovascular mortality is high, reaching 59% in a study by Rodés-Cabau et al. of 339 patients followed for 42 months, which suggests that patient selection needs to be improved.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">SAVR can be a costly procedure in high-risk patients, with an additional cost of 2400 euros in hospital charges for each 1% increase in the Society of Thoracic Surgeons score,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> but it is not known whether TAVI can reduce these costs. In the US, the additional cost of TAVI per life-year gained is around 40 000 euros compared with standard care in inoperable patients.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> The PARTNER trial recently demonstrated that in 80% of cases the costs of SAVR and TAVI do not differ significantly at one year of follow-up.</p><p id="par0070" class="elsevierStylePara elsevierViewall">It was against this background that the ESC/EACTS guidelines on the management of valvular heart disease were issued, which demonstrate the importance of this sophisticated and revolutionary technique in patients considered unsuitable for SAVR.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Minimum technical conditions, clinical indications, additional costs, and outcome assessment</span><p id="par0075" class="elsevierStylePara elsevierViewall">The Working Group recognizes the importance of TAVI programs being run by formally established multidisciplinary teams in centers of excellence with on-site cardiac surgery. Each team should include at least a cardiac surgeon, an interventional cardiologist, an anesthesiologist and a cardiologist experienced in echocardiography. The procedures should be performed in a hybrid operating room, a cardiac catheterization laboratory equipped as an operating room, or an operating room equipped with an imaging system of appropriate quality. Extracorporeal circulation should be available if required.</p><p id="par0080" class="elsevierStylePara elsevierViewall">With regard to the clinical indications in the guidelines (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), we should bear in mind the constraints of the International Monetary Fund financial bailout in Portugal and the publications suggesting that TAVI should only be performed in carefully selected patients in centers with a minimum annual volume of 50 procedures, in order to keep additional costs at an acceptable level and to maintain proficiency.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">It is therefore recommended that TAVI programs should preferentially treat inoperable patients with a class I recommendation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Patients with a class IIa recommendation should be considered for TAVI if:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">the risk-benefit ratio is favorable in terms of quality of life as assessed by the heart team;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">the center considers that the indication is compatible with the experience of the team and the predicted annual volume of procedures<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">the procedure is performed under the scope of investigational studies or registries.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">The consensus is that the use of TAVI should be rigorously monitored, preferably through a national multicenter registry using the current VARC criteria to ensure quality and transparency.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a> It is recommended that all patients be followed for seven years and that nationwide studies be undertaken in Portugal to assess the costs of the technique.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The Working Group hopes that this document will be useful to health professionals, institutions, departments and decision-making bodies dealing with this important and rapidly developing treatment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">TAVI is the only effective treatment for patients with aortic stenosis who are considered unsuitable for surgery.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The technique should be performed in centers of excellence that have a formally established and trained multidisciplinary heart team, treat a minimum of 50 cases a year, have appropriate technical conditions, and keep a prospective registry for monitoring purposes.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protection of human and animal subjects</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Confidentiality of data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Right to privacy and informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres298786" "titulo" => array:4 [ 0 => "Abstract" 1 => "Objective" 2 => "Methods and Results" 3 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec281810" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres298787" "titulo" => array:4 [ 0 => "Resumo" 1 => "Objetivo" 2 => "Métodos e resultados" 3 => "Conclusão" ] ] 3 => array:2 [ "identificador" => "xpalclavsec281811" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Preamble" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Current evidence on transcatheter aortic valve implantation and the situation in Portugal" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Minimum technical conditions, clinical indications, additional costs, and outcome assessment" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-01-21" "fechaAceptado" => "2013-02-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec281810" "palabras" => array:6 [ 0 => "Aortic stenosis" 1 => "Transcatheter aortic valve implantation" 2 => "Recomendations" 3 => "Consensus" 4 => "Experts" 5 => "Working group" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec281811" "palabras" => array:6 [ 0 => "Estenose aórtica" 1 => "Válvulas aórticas percutâneas transcatéter" 2 => "Recomendações" 3 => "Consenso" 4 => "Peritos" 5 => "Grupo de trabalho" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the clinical indications and guidelines for transcatheter aortic valve implantation (TAVI) and to propose adaptations for its use in Portugal.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods and Results</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The working group analyzed the epidemiology of aortic stenosis and current clinical recommendations in the light of current evidence, taking into consideration their own experience in Portugal.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The evidence shows that TAVI significantly reduces mortality in patients with severe aortic stenosis considered unsuitable for surgery. This technique has a comparable safety profile, efficacy and quality of life improvement to conventional surgery in patients with high surgical risk, when carefully selected by multidisciplinary teams.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">TAVI procedures should be performed within multidisciplinary programs in centers with on-site cardiac surgery by experienced teams treating no fewer than 50 cases per year in order to maintain proficiency.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The technique is little used in Portugal, with seven implantations/year per million population, a seventh of the European average and the lowest rate in Europe.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">From a societal standpoint, it is important to evaluate clinical outcomes and analyze the incremental cost involved in order to define the situations in which the technique is appropriate and should be used.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">TAVI is the only treatment for severe aortic stenosis in patients unsuitable for surgery, and can also be applied in selected cases with high surgical risk.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Patients who are considered for this treatment should be evaluated in centers of excellence performing the technique and with a formal program of multidisciplinary team work. The first cases should be supervised until the team has established its routine. The program should perform the recommended minimum number of procedures per year in order to maintain proficiency and must keep a prospective clinical registry for monitoring purposes.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Avaliar as indicações e recomendações clínicas sobre a implantação de válvulas aórticas percutâneas (VAP) e propor adaptações para a sua aplicabilidade em Portugal.</p> <span class="elsevierStyleSectionTitle" id="sect0035">Métodos e resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O grupo de trabalho analisou a epidemiologia da estenose aórtica, avaliou as recomendações clínicas existentes à luz da evidência científica conhecida e baseou-se na sua experiência em Portugal.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A evidência demonstra que as biopróteses valvulares percutâneas reduzem de forma muito significativa a mortalidade dos doentes com estenose aórtica grave considerados inoperáveis. Comparada com a cirurgia convencional, esta técnica apresenta um padrão comparável de segurança, de eficácia e de melhoria da qualidade de vida em doentes de elevado risco cirúrgico, devidamente selecionados por equipas multidisciplinares. Porém há preocupações relativamente à sua durabilidade e segurança a longo prazo.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">De forma a ser proficiente, a implantação de válvulas aórticas percutâneas deve ser realizada no âmbito de programas multidisciplinares integrados desenvolvidos em centros médico-cirúrgicos com equipas experientes, em número não inferior a 50 casos por centro/ano.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Em Portugal observa-se uma utilização muito reduzida desta terapêutica, com sete implantes/ano por milhão de habitantes, o que corresponde a cerca de sete vezes menos do que a média europeia, constituindo a taxa mais baixa da mesma.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Para a sociedade, é necessário avaliar os resultados clínicos e estudar o custo incremental associado para definir quais as indicações em que esta técnica pode e deve ser selecionada.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Conclusão</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A implantação transcatéter de válvulas aórticas percutâneas constitui a única terapêutica para doentes inoperáveis portadores de estenose aórtica grave. Em casos selecionados pode ser aplicada também em doentes considerados de alto risco cirúrgico.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Os doentes candidatos a este tratamento devem ser avaliados em centros de excelência que realizam estas técnicas e possuam um programa formal de funcionamento com uma equipa multidisciplinar. Esta deve ser assessorada nos primeiros casos, até estar rotinada. O programa deve assegurar o mínimo recomendado de casos anuais para manter a sua proficiência, elaborando um registo prospetivo monitorizável.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Campante Teles R, Ribeiro VG, Patrício L, et al. Posição de consenso sobre válvulas aórticas percutâneas transcatéter em Portugal. Rev Port Cardiol. 2013;32:801–805.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">SAVR: surgical aortic valve replacement; TAVI: transcatheter aortic valve implantation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">ESC/EACTS recommendation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Class of recommendation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TAVI should only be undertaken with a multidisciplinary ‘heart team’ including cardiologists and cardiac surgeons and other specialists if necessary. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TAVI should only be performed in hospitals with cardiac surgery on-site. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TAVI is indicated in patients with severe symptomatic aortic stenosis who are not suitable for SAVR and who are likely to gain improvement in their quality of life and to have a life expectancy of more than one year after consideration of their comorbidities. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TAVI should be considered in high-risk patients with severe symptomatic aortic stenosis who may still be suitable for surgery, but in whom TAVI is favored by a heart team based on the individual risk profile and anatomic suitability. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab437327.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines for the use of TAVI according to class of recommendation and level of evidence.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 5 | 16 |
| 2024 October | 50 | 31 | 81 |
| 2024 September | 53 | 23 | 76 |
| 2024 August | 69 | 23 | 92 |
| 2024 July | 57 | 29 | 86 |
| 2024 June | 47 | 15 | 62 |
| 2024 May | 71 | 24 | 95 |
| 2024 April | 36 | 19 | 55 |
| 2024 March | 34 | 18 | 52 |
| 2024 February | 44 | 20 | 64 |
| 2024 January | 50 | 19 | 69 |
| 2023 December | 28 | 24 | 52 |
| 2023 November | 39 | 20 | 59 |
| 2023 October | 23 | 18 | 41 |
| 2023 September | 21 | 20 | 41 |
| 2023 August | 20 | 15 | 35 |
| 2023 July | 23 | 10 | 33 |
| 2023 June | 18 | 12 | 30 |
| 2023 May | 37 | 27 | 64 |
| 2023 April | 26 | 5 | 31 |
| 2023 March | 49 | 21 | 70 |
| 2023 February | 28 | 14 | 42 |
| 2023 January | 26 | 24 | 50 |
| 2022 December | 29 | 23 | 52 |
| 2022 November | 51 | 28 | 79 |
| 2022 October | 21 | 25 | 46 |
| 2022 September | 33 | 44 | 77 |
| 2022 August | 25 | 35 | 60 |
| 2022 July | 31 | 41 | 72 |
| 2022 June | 25 | 22 | 47 |
| 2022 May | 32 | 29 | 61 |
| 2022 April | 22 | 25 | 47 |
| 2022 March | 29 | 53 | 82 |
| 2022 February | 32 | 38 | 70 |
| 2022 January | 18 | 23 | 41 |
| 2021 December | 21 | 34 | 55 |
| 2021 November | 37 | 33 | 70 |
| 2021 October | 47 | 36 | 83 |
| 2021 September | 13 | 22 | 35 |
| 2021 August | 31 | 30 | 61 |
| 2021 July | 19 | 25 | 44 |
| 2021 June | 19 | 18 | 37 |
| 2021 May | 24 | 37 | 61 |
| 2021 April | 24 | 28 | 52 |
| 2021 March | 46 | 26 | 72 |
| 2021 February | 61 | 9 | 70 |
| 2021 January | 34 | 16 | 50 |
| 2020 December | 34 | 6 | 40 |
| 2020 November | 37 | 14 | 51 |
| 2020 October | 17 | 3 | 20 |
| 2020 September | 42 | 4 | 46 |
| 2020 August | 23 | 12 | 35 |
| 2020 July | 49 | 3 | 52 |
| 2020 June | 29 | 3 | 32 |
| 2020 May | 46 | 5 | 51 |
| 2020 April | 51 | 7 | 58 |
| 2020 March | 40 | 5 | 45 |
| 2020 February | 109 | 40 | 149 |
| 2020 January | 59 | 8 | 67 |
| 2019 December | 31 | 3 | 34 |
| 2019 November | 46 | 16 | 62 |
| 2019 October | 43 | 4 | 47 |
| 2019 September | 35 | 6 | 41 |
| 2019 August | 35 | 2 | 37 |
| 2019 July | 47 | 11 | 58 |
| 2019 June | 29 | 5 | 34 |
| 2019 May | 37 | 6 | 43 |
| 2019 April | 44 | 21 | 65 |
| 2019 March | 151 | 9 | 160 |
| 2019 February | 92 | 10 | 102 |
| 2019 January | 57 | 5 | 62 |
| 2018 December | 53 | 6 | 59 |
| 2018 November | 160 | 7 | 167 |
| 2018 October | 321 | 14 | 335 |
| 2018 September | 90 | 15 | 105 |
| 2018 August | 60 | 9 | 69 |
| 2018 July | 39 | 9 | 48 |
| 2018 June | 50 | 8 | 58 |
| 2018 May | 69 | 8 | 77 |
| 2018 April | 101 | 4 | 105 |
| 2018 March | 122 | 8 | 130 |
| 2018 February | 58 | 4 | 62 |
| 2018 January | 174 | 7 | 181 |
| 2017 December | 191 | 5 | 196 |
| 2017 November | 61 | 15 | 76 |
| 2017 October | 40 | 15 | 55 |
| 2017 September | 42 | 9 | 51 |
| 2017 August | 37 | 11 | 48 |
| 2017 July | 28 | 15 | 43 |
| 2017 June | 48 | 6 | 54 |
| 2017 May | 45 | 6 | 51 |
| 2017 April | 27 | 5 | 32 |
| 2017 March | 31 | 42 | 73 |
| 2017 February | 39 | 4 | 43 |
| 2017 January | 31 | 10 | 41 |
| 2016 December | 39 | 16 | 55 |
| 2016 November | 48 | 10 | 58 |
| 2016 October | 40 | 7 | 47 |
| 2016 September | 29 | 10 | 39 |
| 2016 August | 11 | 4 | 15 |
| 2016 July | 23 | 8 | 31 |
| 2016 June | 14 | 2 | 16 |
| 2016 May | 29 | 4 | 33 |
| 2016 April | 40 | 2 | 42 |
| 2016 March | 60 | 32 | 92 |
| 2016 February | 71 | 42 | 113 |
| 2016 January | 48 | 34 | 82 |
| 2015 December | 47 | 15 | 62 |
| 2015 November | 58 | 24 | 82 |
| 2015 October | 60 | 26 | 86 |
| 2015 September | 46 | 23 | 69 |
| 2015 August | 52 | 22 | 74 |
| 2015 July | 52 | 13 | 65 |
| 2015 June | 29 | 4 | 33 |
| 2015 May | 73 | 14 | 87 |
| 2015 April | 31 | 26 | 57 |
| 2015 March | 30 | 13 | 43 |
| 2015 February | 34 | 6 | 40 |
| 2015 January | 51 | 15 | 66 |
| 2014 December | 51 | 26 | 77 |
| 2014 November | 43 | 11 | 54 |
| 2014 October | 47 | 17 | 64 |
| 2014 September | 48 | 21 | 69 |
| 2014 August | 30 | 13 | 43 |
| 2014 July | 41 | 14 | 55 |
| 2014 June | 31 | 11 | 42 |
| 2014 May | 34 | 18 | 52 |
| 2014 April | 21 | 15 | 36 |
| 2014 March | 42 | 22 | 64 |
| 2014 February | 46 | 24 | 70 |
| 2014 January | 77 | 23 | 100 |
| 2013 December | 22 | 13 | 35 |
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