Temporal Trends and Clinical Consequences of Wait-Times for Trans-Catheter Aortic Valve Replacement: A Population Based Study.

Abstract

Background -Trans-catheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait-times. Our objective was to evaluate temporal trends in TAVR wait-times and the associated clinical consequences. Methods -In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1st, 2010 to March 31st, 2016. The primary outcome was the median total wait-time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVR wait-times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait-list. Results -The study cohort included 4,461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons and 11% remained on the wait-list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait-time in the post-reimbursement period stabilized at 80 days and has remained unchanged. The cumulative probability of wait-list mortality and heart failure hospitalization at 80 days was approximately 2% and 12% respectively, with a relatively constant increase in events with increased wait-times. Conclusions -Post-reimbursement wait-time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait-time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.