Association between quality of care indicators and clinical outcomes in patients undergoing transcatheter aortic valve implantation: insights from SWEDEHEART

Background Transcatheter Aortic Valve Implantation (TAVI) has become an established procedure for treating severe aortic stenosis, particularly in patients who are considered high or intermediate risk for conventional surgical aortic valve replacement. As the procedure becomes more widely available, ensuring high-quality care and optimal patient outcomes is increasingly important, and here quality indicators (QIs) might have an important role. The European Society of Cardiology (ESC) has developed QIs specifically for the care and outcomes for patients undergoing TAVI. To further establish the QIs, an evaluation of the quality of care against the QIs is warranted which was the aim of this study. Purpose To evaluate TAVI care using the ESC 2023 QIs for TAVI. Methods We used the Swedish Transcatheter Cardiac Intervention Registry to identify all TAVI procedures performed in Sweden between 2008-2021. Data was further linked with the Swedish Coronary Angiography and Angioplasty Registry, the Swedish Coronary Surgery Registry and the National Patient Registry to identify interventions and hospitalisations. Results A total of 8524 patients undergoing TAVI in Sweden between 1 January 2008 and 31 December 2021 at 8 different centres were included. For the quality indicators, 24 (77.7%) out of the 27 QIs for TAVI were able to capture from available registry data. The attainment levels were high in general (median 97.8%, interquartile range [IQR] 91.3-100%). There were overall small variations in attainment levels between centres. The greatest variations were in the QIs concerning the proportion of patients undergoing TAVI through transfemoral route (IQR 85.6-96.9%), and in the proportion of patients undergoing transfemoral route TAVI without general anaesthesia with IQR 57.1-94.4% (Figure 1). In total, 75% of the QIs were associated with an increased or decreased all-cause mortality, and 85% of the QIs were associated with cardiovascular mortality. In addition, 5 out of 20 measurable QIs (25%) were significantly associated with improved heart failure hospitalisation at 12 months, The QI with greatest impact on one-year mortality was no coronary obstruction (adjusted HR 0.12 ; 95% CI 0.07-0.22) followed by no in-hospital stroke (adjusted HR 0.25 ; 95% CI 0.18-0.33) and no new dialysis (adjusted HR 0.25 ; 95% CI 0.15-0.41), Figure 2. Conclusion The ESC 2023 quality indicators for TAVI could be used to evaluate TAVI care. In this study, the majority of the QIs were associated with all-cause and cardiovascular mortality. The QIs may be an important tool for benchmarking and to improve patient outcomes after TAVI.