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Transcatheter aortic valve implantation (TAVI) a reference model in percutaneous cardiovascular intervention
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Cardiovascular diseases (CVDs) are the leading causes of death and hospitalization and
represent an enormous clinical and public health burden, which disproportionately affects older
adults. According to the Instituto Nacional de Estatística (INE), life-expectancy at born and at 65
years has increased, respectively, 9,6% (73,93 to 81,06 years) and 5,1% (80,60 to 84,69 years),
between 1990 and 2020. This evolution is observed worldwide and the World Health
Organization (WHO) expects octogenarians to quadruple to 396 million by 2050. The 2060 INE
estimates for life expectancy at born in Portugal are 84,21 years for men and 89,88 years for
women1,2. This has increased the relative importance of heart valve diseases whose prevalence
reached more than one in every ten octogenarians.
This document summarizes a coherent professional path dedicated to the cardiovascular area,
marked by the search for professional excellence, based on solid evidence-based clinical
experience, phased research and the constant challenge of technical-scientific evolution.
In the following pages, you will find the testimony of the drastic change caused by the structural
cardiac intervention model in the aortic valve, with consequences in the organization and
training of cath labs, as well as in the entire Cardiology department in terms of care and
investigations.
Before becoming a cardiologist, I intended already to be an interventional cardiologist and it
was with the formulation of this question that I first addressed Prof. Dr. Ricardo Seabra-Gomes,
in 1996. His provocative answer has since then placed the responsibility over my shoulders by
the success, or not, of this ambition. The endeavor was, and still is, extremely demanding - no
more than for everyone - and guided by the critical spirit of the tutored clinical activity in the
light of emerging evidence-based medicine.
Hospital de Santa Cruz is a pioneer unit in several techniques and percutaneous coronary
intervention assumed dominance in 1990, when it surpassed, in number, surgical myocardial
revascularization.
In 2008 the Cardiology Director, Dr. Aniceto Silva, accepted my proposal for the organization,
structuring and development of a program based on the individualized approach of each
patient, using all types of percutaneous and other techniques - and all sorts of devices. Thus, it
was born the Percutaneous Valves (VaP) program, transversal between Cardiology and Cardiac
Surgery, encompassing referral, assessment, patient study, multidisciplinary meetings,
discharge and follow-up during the consultation. Parallel and progressively, there was a strong pedagogical and training project to endow the team with a critical mass that allowed the senior
operators to achieve autonomy and transversal competence, like that of coronary intervention,
unique in the national reality. Finally, several international research consortia were conquered
and integrated, in parallel with the international path followed that culminates in the
prestigious Board of the European Association of Interventional Cardiology (EAPCI).
Safety and efficacy have always been the first requirements for any cardiovascular technique,
because mortality and complications are extremely important from a clinical point of view,
resulting in prolonged admission and increased hospital costs. Coordinating the structural
program is an enormous challenge that intersects all professional groups and colleagues, from
resident to the cardiology head, highlighting the importance of building and caring for the
referral network. It essentially went through four phases, each requiring an adaptation of the
clinical, organizational, research, communication and management strategic plan:
I. From 2008 to 2013, the technical and device launch phase, with a concentration of the
volume on the three most experienced operators, intensive use of imaging and general
anesthesia as default;
II. From 2014 to 2016, the strategic innovation and sustained growth phase, with the
expansion of the team to other senior operators, with the use of new techniques and devices -
including mitral valves - with the cautious introduction of more simplified protocols for TAVI
anesthesia and replication of image expertise to non-aortic space. The institution became a
national leader and the period includes an official institutional survey that creates waiting lists
in 2015 and provides a growth opportunity. The Presidency of Associação Portuguesa de
Cardiologia de Intervenção (APIC) poses challenges and provides national and international
collaborative opportunities that were distant, until then;
III. From 2016 to 2017, the accelerated growth phase to respond to waiting lists and achieve
maturation in the entire structural field. The visit of similar institutions is carried out with the
adoption of an innovative model of sedation-analgesia with the support of anesthesiology, the
teaching of the technique to all senior operators as well as the simplification of intra-hospital
processes. The space of transseptal techniques enlarges and with it, all the imaging knowledge.
Integration into EAPCI's European Valve For Live project projects APIC into EAPCI. The invitation
to join its Board is challenging and allows you to competitively integrate prestigious European
and North American research consortia.
IV. From 2018 onwards, the consolidation phase, that is based on the daily routine of
structural intervention techniques, with underlying administrative coordination and the
implementation of a long-distance program that concentrates clinical examinations and evaluations in a single day. There is a growing and unique transversal experience that makes
the center the Iberian leader in TAVI and that makes it a hands-on training center for other
centers such as Centro Hospitalar do Funchal and Centro Hospitalar da Universidade de
Coimbra, in addition to very important care partnerships with the Hospital Garcia de Orta,
Hospital Fernando da Fonseca and Centro Hospitalar de Leiria.
The biggest current challenge is to provide our network with a simple, expeditious and efficient
articulation, expanding the center's narrative to the area of quality from the perspective of the
patient and the referrer, based on scientific research within the scope of consortia. Other
challenges, such as percutaneous mitral and tricuspid valve intervention, closure of the left atrial
appendage and percutaneous closure of valve leaks, arise from this maturity and become a
natural evolution in the field of percutaneous structural interventions.
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TAVI