Canadian patients can wait up to 60 percent longer for a TAVR procedure depending on where they live

New study published in the Canadian Journal of Cardiology highlights significant differences across Canada in wait-times for transcatheter aortic valve replacement (TAVR)


Philadelphia, April 29, 2020

Transcatheter aortic valve replacement (TAVR) is a revolutionary technology for the treatment of patients with severe calcific aortic stenosis. Demand for TAVR has grown tremendously across Canada, but there are significant differences in capacity and wait-times across the country with some patients waiting up to 60 percent longer for the procedure, report investigators in the Canadian Journal of Cardiology, published by Elsevier.

Aortic stenosis restricts the blood flow from the left ventricle to the aorta, reducing blood flow to the rest of the body, and may also affect the pressure in the left atrium. TAVR has emerged as the treatment of choice for elderly patients suffering from severe aortic stenosis. A minimally invasive surgical procedure, it repairs the valve without removing the old, damaged valve. Instead, the procedure “wedges” a replacement valve into the aortic valve's place via a catheter inserted through a blood vessel in the leg or chest. Importantly, it can be performed in patients with medical conditions that make them unfit for full open heart surgery.

“In the past, such patients needed open heart surgery for surgical aortic valve replacement or would be untreated,” explained lead investigator Harindra C. Wijeysundera, MD, PhD, Schulich Heart Centre, Divisions of Cardiology and Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto; Institute for Clinical Evaluative Sciences (ICES); and Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada. “TAVR is a transformative treatment. There has been an exponential growth in demand in Canada. However, in some provinces there has not been a corresponding growth in capacity.”

Investigators looked at the increase in the number of procedures across Canada and determined whether there are differences in access based on wait-times depending on geographic location. TAVR procedures are currently performed by 29 TAVR programs, which involve 31 hospitals across nine of the 12 Canadian provinces and territories. Researchers identified nearly 5,000 TAVR procedures that took place from April 1, 2014 to March 31, 2017 across these nine provinces. Wait-time was defined as the number of days from the initial referral for the TAVR procedure. They found that despite a year-over-year increase in overall capacity, there was a greater than three-fold difference in capacity among provinces.

They also noted a marked variation in wait-times across Canada, for example, from 71.5 days in Newfoundland to 190.5 and 203 days in Manitoba and Alberta, respectively. On average, the same patient could potentially wait up to sixty percent longer in some provinces compared to others.

“The current study is very concerning in that there are long waits for TAVR and that these are markedly different across the country. Being on the waiting list for TAVR for long periods is associated with increased risk of death and hospitalization,” noted Dr. Wijeysundera. “Such inequity is a call for policy makers across Canada to re-evaluate provincial funding mechanisms for this therapy to ensure that every Canadian has access to the standard of care for aortic stenosis in a timely fashion.”

In an accompanying editorial, Janarthanan Sathananthan, MBChB, MPH, and Kenneth Gin, MD, both of the Centre for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia; Centre for Cardiovascular Innovation, University of British Columbia; and Vancouver General Hospital, Vancouver Coastal Health, Vancouver, BC, Canada, noted that in Canada, TAVR is currently offered predominantly to patients of high and intermediate surgical risk. “As TAVR expands to low risk patients with increasing demand on TAVR services, these inequalities may continue to worsen and may result in poor outcomes,” added Dr. Sathananthan.

The ability to increase patient capacity and reduce waiting time does not necessarily require an increase in resources wrote Dr. Sathananthan and Dr. Gin, observing that in some situations, inequalities can be reduced by improving processes of care. Two recently reported studies have demonstrated that by optimizing and delivering consistent care before, during, and after the procedure, patients can achieve a high rate of safe next-day discharge, which has the potential to increase both access to care and patient volume, while using current resources.

“While achieving consistent, reproducible care is desirable at a center level, there is a need for national guidelines for TAVR care across Canada,” commented Dr. Gin. “Improving access to healthcare for TAVR patients will require both provincial and national coordination. This is of importance as TAVR increasingly becomes an accepted alternative to surgical aortic valve replacement for patients with severe calcific aortic stenosis.”

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Notes for editors
The article is “Inequity in Access to Transcatheter Aortic Valve Replacement: A Pan-Canadian Evaluation of Wait-Times,” by Harindra C. Wijeysundera, MD, PhD, Kayley A. Henning, MPH, Feng Qiu, MSc, Corey Adams, MD, MMSc, Faisal Al Qoofi, MD, Anita Asgar, MD, MSc, Peter Austin, PhD, Kevin R. Bainey, MD, MSc, Eric A. Cohen, MD, Benoit Daneault, MD, Stephen Fremes, MD, Malek Kass, MD, Dennis T. Ko, MD, MSc, Laurie Lambert, PhD, Sandra B. Lauck, PhD, Kendra MacFarlane, MSc, Syed Najaf Nadeem, MD, Garth Oakes, PhD, Vernon Paddock, MD, Marc Pelletier, MD, Mark Peterson, MD, Nicolo Piazza, MD, Brian J. Potter, MD, Sam Radhakrishnan, MD, Josep Rodes-Cabau, MD, Olga Toleva, MD, John G. Webb, MD, Robert Welsh, MD, David Wood, MD, Graham Woodward, MSc, and Rodney Zimmermann, MD (https://doi.org/10.1016/j.cjca.2019.10.018).

The editorial is “How Do We Address Health Care Inequalities for Transcatheter Aortic Valve Implantation in Canada?” by Janarthanan Sathananthan, MBChB, MPH, and Kenneth Gin, MD (https://doi.org/10.1016/j.cjca.2020.01.017). They appear in the Canadian Journal of Cardiology, volume 36, issue 6 (June 2020) published by Elsevier.

The study is funded in part by the Ministry of Research and Innovation of Ontario and investigator-initiated grants from Medtronic Inc., and Edwards Lifesciences.

Full text of the articles is available to credentialed journalists upon request. Contact Eileen Leahy at +1 732 238 3628 or cjcmedia@elsevier.com to obtain copies. Journalists wishing to speak to the study’s authors should contact Katherine Nazimek, Communications Advisor, Communications & Stakeholder Relations, at +1 416 480 6100 ext. 2250 or katherine.nazimek@sunnybrook.ca. To reach the editorial’s authors for comment, please contact Kenneth Gin, MD, at +1 604 875 5898 or kenneth.gin@vch.ca.

About the Canadian Journal of Cardiology
The Canadian Journal of Cardiology is the official journal of the Canadian Cardiovascular Society. It is a vehicle for the international dissemination of new knowledge in cardiology and cardiovascular science, particularly serving as a major venue for the results of Canadian cardiovascular research and Society guidelines. The journal publishes original reports of clinical and basic research relevant to cardiovascular medicine as well as editorials, review articles, case reports, and papers on health outcomes, policy research, ethics, medical history, and political issues affecting practice. www.onlinecjc.ca

About the Editor-in-Chief
Editor-in-Chief Stanley Nattel, MD, is Paul-David Chair in Cardiovascular Electrophysiology and Professor of Medicine at the University of Montreal and Director of the Electrophysiology Research Program at the Montreal Heart Institute Research Center.

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers. www.elsevier.com

Media contact
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Elsevier
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cjcmedia@elsevier.com