BACKGROUND The Institut national d'excellence en santé et en services sociaux (INESSS) has collaborated with Québec's transcatheter aortic valve implantation (TAVI) programs since 2013 to evaluate processes of care and outcomes. In 2018-2019, data were also collected on surgical aortic valve replacement (SAVR). Herein, we describe real-world volume and outcome trends for these two patient groups, as well as processes of care and clinical characteristics over a 6-month period. METHODS AND RESULTS Volume and mortality have been ascertained for TAVI since 2013 in collaboration with all Québec programs, and from the Canadian Institute for Health Information (CIHI) for SAVR. From October 1, 2018 to March 31, 2019, patient characteristics and process of care data were also collected, in collaboration with clinical teams, for all TAVI and SAVR performed in patients aged ≥ 75 years. Rates of TAVI doubled between 2013-2014 and 2018-2019 (9.4 to 19.6 / 100,000 population), whereas rates of isolated SAVR (iSAVR) remained stable (19.8 to 21.5 / 100,000 population). Thirty-day mortality post-TAVI decreased from 4.8% in 2013-2016 to 2.4% in 2016-2019 amongst patients ≥ 75 years, and from 3.7% to 2.3% in younger patients. For iSAVR, 30-day mortality during the same periods decreased in patients ≥ 75 years, from 3.2% to 1.0%, but remained stable (at 1.0%) in younger patients. During the 6-month 2018-2019 period, 300 TAVI and 129 iSAVR in patients ≥ 75 years were examined. TAVI patients had a higher median age than iSAVR (84 vs. 78) and more comorbidities. For TAVI, median delay from referral to treatment decision was 72 days (inter-quartile range, IQR: 11-138) and 28 days (IQR: 7-75) from decision to procedure; for iSAVR, these were 17 (IQR: 1-49) and 63 days (IQR: 16-109), respectively. Median length of hospital stay was 3 days (IQR: 1-5) for TAVI, and 7 days (IQR: 6-10) for iSAVR. Incidence of in-hospital stroke, new pacemaker and 30-day mortality was 3.3%, 17.7% and 2.3% for TAVI, respectively, and 1.6%, 6.2% and 0% for iSAVR. CONCLUSION From 2013-2019, use of TAVI increased and a decrease in overall 30-day mortality associated with treatment for severe and symptomatic aortic stenosis was observed. Amongst elderly patients in 2018-2019, TAVI and SAVR patients had different characteristics, evaluation processes and wait times. Broadening of TAVI to patients at low surgical risk raises organizational and long-term clinical issues and may favour a shift from procedure-focused to disease-centred evaluation processes. The Institut national d'excellence en santé et en services sociaux (INESSS) has collaborated with Québec's transcatheter aortic valve implantation (TAVI) programs since 2013 to evaluate processes of care and outcomes. In 2018-2019, data were also collected on surgical aortic valve replacement (SAVR). Herein, we describe real-world volume and outcome trends for these two patient groups, as well as processes of care and clinical characteristics over a 6-month period. Volume and mortality have been ascertained for TAVI since 2013 in collaboration with all Québec programs, and from the Canadian Institute for Health Information (CIHI) for SAVR. From October 1, 2018 to March 31, 2019, patient characteristics and process of care data were also collected, in collaboration with clinical teams, for all TAVI and SAVR performed in patients aged ≥ 75 years. Rates of TAVI doubled between 2013-2014 and 2018-2019 (9.4 to 19.6 / 100,000 population), whereas rates of isolated SAVR (iSAVR) remained stable (19.8 to 21.5 / 100,000 population). Thirty-day mortality post-TAVI decreased from 4.8% in 2013-2016 to 2.4% in 2016-2019 amongst patients ≥ 75 years, and from 3.7% to 2.3% in younger patients. For iSAVR, 30-day mortality during the same periods decreased in patients ≥ 75 years, from 3.2% to 1.0%, but remained stable (at 1.0%) in younger patients. During the 6-month 2018-2019 period, 300 TAVI and 129 iSAVR in patients ≥ 75 years were examined. TAVI patients had a higher median age than iSAVR (84 vs. 78) and more comorbidities. For TAVI, median delay from referral to treatment decision was 72 days (inter-quartile range, IQR: 11-138) and 28 days (IQR: 7-75) from decision to procedure; for iSAVR, these were 17 (IQR: 1-49) and 63 days (IQR: 16-109), respectively. Median length of hospital stay was 3 days (IQR: 1-5) for TAVI, and 7 days (IQR: 6-10) for iSAVR. Incidence of in-hospital stroke, new pacemaker and 30-day mortality was 3.3%, 17.7% and 2.3% for TAVI, respectively, and 1.6%, 6.2% and 0% for iSAVR. From 2013-2019, use of TAVI increased and a decrease in overall 30-day mortality associated with treatment for severe and symptomatic aortic stenosis was observed. Amongst elderly patients in 2018-2019, TAVI and SAVR patients had different characteristics, evaluation processes and wait times. Broadening of TAVI to patients at low surgical risk raises organizational and long-term clinical issues and may favour a shift from procedure-focused to disease-centred evaluation processes.

Most current guidelines have weak recommendations for short term dual antiplatelet therapy (DAPT) use after transcatheter aortic valve replacement (TAVR). There also has been growing interest for anticoagulation therapy after TAVR, but it’s role remains a subject of debate. Some authors have suggested that anticoagulation post TAVR might prevent both clinical and subclinical thrombosis of the prosthetic valve. Yet, there is little data on anticoagulation and its impact on the valve’s long-term hemodynamics, with hemodynamic deterioration remaining of uncertain clinical significance. This study aimed to compare the evolution of transvalvular gradients and aortic valvular area (AVA) post TAVR according to use of anticoagulation therapy. This monocentric retrospective study included 128 patients who underwent TAVR at the Centre hospitalier universitaire de Sherbrooke between 2011 and 2018. Anticoagulation was prescribed at discharge after TAVR in a total of 52 patients (41%), and 76 patients (59%) were left on antiplatelet therapy alone. All available follow-up echocardiographic data was analyzed, and mixed linear models were used to compare the evolution of transvalvular gradients and AVA between the two groups. A total of 439 echocardiograms, over a median follow-up of 18 months (1 to 78 months), were included for analysis. Secondary outcomes included ischemic events, bleeding, and rehospitalization at one year. Anticoagulated patients had more atrial fibrillation (88.5 vs 2.6%, p < 0.0001), including permanent AF (62.7 vs 1.3%), and a smaller baseline mean aortic gradient (38.3 vs 46.5 mmHg, p = 0.002). The evolution of the mean aortic gradient over time did not significantly differ in time between the two groups (p=0.85). The mean aortic gradient was significantly higher in the non-anticoagulated group (p = 0.03), but this difference was noted from baseline and was constant throughout follow-up. The mean aortic gradient increased significantly in time in both groups. The AVA (p = 0.98) or its evolution in time (p = 0.47) did not differ significantly between the two groups. It also did not significantly change in time for neither the anticoagulation of non-anticoagulated groups. No significant difference was found with regards to secondary outcomes. In this study, anticoagulation after TAVR was not associated with slower hemodynamic deterioration of the prosthetic valve. Anticoagulated patients had lower transvalvular gradients, but similar AVA. This could be the reflect of lower flow in anticoagulated patients, of which almost two thirds had permanent AF. Randomized trials are needed to further understand the role of anticoagulation after TAVR.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The clinical tradition of adding oral anticoagulation (OAC) to Background therapy in patients with anterior STEMI and new onset antero-apical wall motion abnormalities (WMA) predates the modern reperfusion era. Evidence for the continued pertinence of this practice in the setting of timely primary percutaneous coronary intervention (pPCI) and widespread use of newer P2Y12-inhibitors is lacking. Clinicians are therefore faced with a therapeutic dilemma in balancing ischemic and hemorrhagic risks that remains unsettled. The objective of this on-going cohort study is to test the hypothesis that dual antiplatelet therapy (DAPT) alone provides a similar net clinical benefit compared to the combination of DAPT+OAC in these patients. A multicenter retrospective analysis was performed in 4 high-volume Canadian academic centers. Consecutive patients referred for anterior STEMI and treated with pPCI between 2010-2015 with documented new-onset anterior or apical wall motion abnormalities were eligible for inclusion. Patients discharged on DAPT alone were compared to patients discharged on DAPT+OAC. The primary composite endpoint of Net Adverse Clinical Events (NACE) endpoint consisted of all-cause death, myocardial infarction, cerebral or systemic thromboembolism, or bleeding at 12 months. All clinical data were retrospectively abstracted from medical charts. Among 1375 patients screened to date, 255 had an anterior STEMI without apical thrombus, met the inclusion/exclusion criteria, and had follow-up at 12 months (DAPT: 158; DAPT+OAC 68; other strategy: 16). Baseline characteristics are shown in the Table, and outcomes in the Figure. A NACE occurred in 21 (13%) and 14 (21%) patients of the DAPT and DAPT+OAC groups, respectively (unadjusted p=0.16). The risk of NACE was similar between both groups following multivariable analysis (OR=0.6 for DAPT; 95%: 0.3-1.5). There was no interaction between left ventricular fraction (LVEF) and anti-thrombotic strategy (p for interaction=0.63). These results were consistent in the following subgroups: LVEF ≤30%, apex involved, akinesis only, and after exclusion of patients requiring OAC for another indication (n=8) (p >0.05 for all subgroups). This multi-center retrospective analysis does not support the addition of OAC To DAPT following acute anterior MI with new-onset antero/apical wall motion abnormality in the setting of pPCI. Alternative combinations of anti-thrombotics, including OAC + antiplatelet monotherapy, may deserve consideration and a randomized controlled trial on this subject would appear warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Current guidelines suggest that the addition of oral anticoagulation (OAC) following anterior STEMI with antero-apical wall motion abnormalities (WMA) may be considered for the prevention of left ventricular thrombus (LVT) formation and its potential subsequent cerebral or systemic embolism. However, the incidence of mural LVT in the current era of timely primary percutaneous coronary intervention (pPCI) and potent dual antiplatelet therapy (DAPT) has not been well described, and needs to be reassessed in order to support this practice. The purpose of this analysis was to define the incidence of LVT in a pPCI population with anterior STEMI and antero-apical WMA. The MAGIC study is a retrospective multicenter registry involving 4 academic centers with pPCI facilities in the province of Québec, designed to improve the care of patients with antero/apical WMA following STEMI. Consecutive patients with an acute anterior STEMI treated with pPCI and presenting new anterior WMA from 2010-2015 were eligible for inclusion. In this substudy, the incidence of LVT in-hospital and at 12 months is reported according these pre-specified criteria: LV ejection fraction (LVEF) ≤30% versus >30%; apical involvement vs. no apical involvement. The effect of the different anti-thrombotic strategies used in this context is reported elsewhere. Among the 367 patients included in this analysis, 18 (5%) presented LVT on baseline echocardiography following pPCI. Pre-procedure and intraprocedural antithrombotic therapy was similar between patients and without LVT (p=NS for all). Patients with LVT had a higher incidence of cardiogenic shock (22% vs. 8%, p=0.03) and lower LVEF (median [IQR]: 26% [20-41%] vs. 40% [35-45%]; p=0.001). Among the 223 patients without LVT at baseline with 12-months follow-up, only 1 (0.4%) developed LVT during follow-up, representing 0.6% of all patients discharged on DAPT only without anticoagulation. It was diagnosed 214 days following the index event. Among the 68 patients for whom all four apical segments were akinetic (51% discharged on DAPT only), and the 39 with an LVEF ≤30% (42% discharged on DAPT only), none developed an LVT. In the current era of early mechanical reperfusion with the availability of novel P2Y12-inhibitors, the acute incidence of LVT following anterior STEMI with antero-apical WMA remains clinically significant. The incidence of LVT during follow-up appears low, but may be underestimated by the retrospective analysis based on chart review. A prospective study that includes mandated contrast-enhanced echocardiography at baseline and follow-up in this patient population is warranted.

INESSS (Institut national d’excellence en santé et en services sociaux) has a ministerial mandate to aid decision-making pertaining to use of transcatheter aortic valve implantation (TAVI) in Québec. As part of a comprehensive evaluation model, we have conducted systematic literature reviews and collected ‘real world’ data since 2013. Provincial quality standards have been formulated via an interactive, deliberative process with clinical experts. Herein, we examine 4 years of TAVI in Québec in light of these provincial standards and the priority quality indicators (QI) proposed by the Canadian Cardiovascular Society (CCS) in 2015. Data were collected by our unit in collaboration with each hospital’s clinical team for all TAVI cases performed from April 1, 2013 to March 31, 2017 using standardized definitions. Data were entered into a secure online portal, providing the clinical teams with real-time access. Provincial annual TAVI volumes from 2013-14 to 2016-17 have consistently increased: 294; 340; 360; 370. Over the 4 years, patient characteristics have remained relatively constant (median age 83 years; 47% female). The Society of Thoracic Surgeons (STS) predicted risk of operative mortality score was 6% (interquartile range, IQR: 4-9) in 2013-14 and 5% (IQR: 4-7) in 2016-17. Medical chart documentation of STS score increased only slightly (50% in 2013-14 to 55% in 2016-17), but varied widely across the 6 TAVI centers (3 - 86% in 2016-17). Heart Team decision and wait times were measured only in the 2 most recent years. Almost all (> 90%) patients had documentation of a Heart Team decision. Delay from referral to decision was 60 days (IQR: 18-112) in 2015-16 versus 44 days (IQR: 15-99) in 2016-17. Median delay from decision to TAVI procedure was 40 days (IQR: 12-82) in 2015-16 versus 42 days (IQR: 14-89) in 2016-17. Over 4 years, in-hospital stroke rates remained stable (2.0%; 4.4%; 2.3%; 3.0%) while mortality at 30 days decreased (6.1%; 4.1%; 2.8%; 3.0%, p=0.03 test for trend). All of these results are very consistent with QI measures reported at the national level in the CCS report for 2013-14. In Québec, TAVI continues to be used in an elderly patient population, but with improving processes of care and declining adverse outcomes. Documentation of CCS priority QIs by clinical teams has improved, permitting measurement of TAVI wait times. New Québec quality standards will ensure better documentation of the patient evaluation and selection process for this evolving technology.

Guidelines surrounding the use of implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death (SCD) in patients diagnosed with heart failure have been established for many years. We suspected discordance between Canadian Cardiovascular Society’s recommendations and current clinical practice. Our goal was to establish the difference between current guidelines and clinical practice as well as factors that significantly influence referral for an ICD. Our perception was that female gender was a factor of non-adherence to ICD guidelines. This retrospective study included 903 consecutive patients that were followed by cardiologists in a specialized heart function clinic. Electronic medical record (Vision C+) collected data from patients seen between May 2005 and February 2017. Patients had to have a documented left ventricular ejection fraction of 35% or less, persistent for at least 90 days. All patients fulfilling these criteria were included except patients in New York Heart Association functional class 4. We described the use of ICD within our group of patients potentially eligible for ICD in primary prevention of SCD. Available variables such as age, sex, medication and comorbidities were analyzed. Of our 903 patients group, 195 (21,6%) were women. Mean age was 71,9 ± 12,5 years. ICD was implanted in 367 (40,6%) patients. CAD was labeled has the cause of HF in 607 (67,2%) of patients. In a multivariate analysis, factors such as age (OR=1,03, p < 0,001), female sex (OR=1,6, p=0,011) and diagnostic of cognitive impairment (OR=3,45, p=0,004) were showed to negatively influence the prescription of an ICD. The prescription of an ICD should be approached individually according to the age, comorbidities and wishes of each patient. The present study suggests that women, independently of age and comorbidities, were significantly less likely than men to receive an ICD. Our group included only 21,6% of women which can possibly be a source a bias. We cannot know for sure if the difference noted is related to wishes and beliefs in our group or if there really is a sex bias within clinical practice. This concern would benefit further evaluation in future studies.

Our cardiovascular evaluation unit has collaborated with Québec’s six transcatheter aortic valve implantation (TAVI) programs since 2013 to evaluate use and outcomes of TAVI. In 2015, the Canadian Cardiovascular Society (CCS) established TAVI quality indicators (QI). Herein, we evaluate these QIs in Québec over a 3-year period.

BackgroundOur publicly funded cardiovascular evaluation unit examined quality indicators relating to the use and outcomes of transcatheter aortic valve implantation (TAVI). We compared results in Québec hospitals with 9 registries around the world.MethodsWe abstracted data on all TAVI cases (n=294) in all 6 Québec TAVI hospitals during a 1-year period (2013-14). Variables, outcomes and definitions were chosen to facilitate comparisons with other registries. Results were presented to Québec’s TAVI teams with the goals of identifying the most appropriate quality indicators and improving clinical practice.ResultsAcross international registries, the number of hospitals varied from 10 to 224, with patient numbers ranging from 418 to almost 8000. The observation period ranged from 2007 to 2014, with some registries reporting results for a single year and others combining up to 5 years. Age was similar across all regstries, with the mean or median being consistently over 80 years. Most registries reported either the STS risk score or a Euroscore, rendering international comparisons difficult; only 3 registries reported both types. The median STS score for Québec was similar to that reported in the USA (6% [interquartile range, IQR: 4-9] vs 7% [IQR: 5-11], respectively). Rates of procedural success varied widely across regions, largely due to non-standardized classification of post-TAVI aortic regurgitation. Renal impairment, bleeding and transfusion were rarely reported and definitions varied. The most frequently reported quality indicators were conversion to surgery, in-hospital stroke, need for a new pacemaker and death. Conversion to surgery occurred in 2.7% in Québec and 0.4%-4.3% internationally. Incidence of in-hospital stroke was 2.2% for Québec and 1.6%-3.3% across registries. New pacemakers were required for 6.6% to 24.8% of patients in registries, and for 14.9% in Québec. In-hospital mortality in Québec was 6.5% versus 5.1% in Austria, 5.5% in USA, 7.3% in Spain, and, in Germany, 5.1% for transvascular and 7.7% for transapical TAVI. Some other registries only reported 30-day mortality, that varied from 4.1% in Australia/New Zealand to 9.2% in France.ConclusionPractice and outcomes of TAVI appear to vary widely across the world, due at least in part to lack of standardized reported outcomes and patient populations, and despite publication of recommended endpoints (VARC and BARC). While quality benchmarks for patient selection and outcomes remain unclear, continued monitoring with timely feedback to TAVI teams and decision-makers is essential for this new and costly intervention that is predominantly being performed in the very elderly. BackgroundOur publicly funded cardiovascular evaluation unit examined quality indicators relating to the use and outcomes of transcatheter aortic valve implantation (TAVI). We compared results in Québec hospitals with 9 registries around the world. Our publicly funded cardiovascular evaluation unit examined quality indicators relating to the use and outcomes of transcatheter aortic valve implantation (TAVI). We compared results in Québec hospitals with 9 registries around the world. MethodsWe abstracted data on all TAVI cases (n=294) in all 6 Québec TAVI hospitals during a 1-year period (2013-14). Variables, outcomes and definitions were chosen to facilitate comparisons with other registries. Results were presented to Québec’s TAVI teams with the goals of identifying the most appropriate quality indicators and improving clinical practice. We abstracted data on all TAVI cases (n=294) in all 6 Québec TAVI hospitals during a 1-year period (2013-14). Variables, outcomes and definitions were chosen to facilitate comparisons with other registries. Results were presented to Québec’s TAVI teams with the goals of identifying the most appropriate quality indicators and improving clinical practice. ResultsAcross international registries, the number of hospitals varied from 10 to 224, with patient numbers ranging from 418 to almost 8000. The observation period ranged from 2007 to 2014, with some registries reporting results for a single year and others combining up to 5 years. Age was similar across all regstries, with the mean or median being consistently over 80 years. Most registries reported either the STS risk score or a Euroscore, rendering international comparisons difficult; only 3 registries reported both types. The median STS score for Québec was similar to that reported in the USA (6% [interquartile range, IQR: 4-9] vs 7% [IQR: 5-11], respectively). Rates of procedural success varied widely across regions, largely due to non-standardized classification of post-TAVI aortic regurgitation. Renal impairment, bleeding and transfusion were rarely reported and definitions varied. The most frequently reported quality indicators were conversion to surgery, in-hospital stroke, need for a new pacemaker and death. Conversion to surgery occurred in 2.7% in Québec and 0.4%-4.3% internationally. Incidence of in-hospital stroke was 2.2% for Québec and 1.6%-3.3% across registries. New pacemakers were required for 6.6% to 24.8% of patients in registries, and for 14.9% in Québec. In-hospital mortality in Québec was 6.5% versus 5.1% in Austria, 5.5% in USA, 7.3% in Spain, and, in Germany, 5.1% for transvascular and 7.7% for transapical TAVI. Some other registries only reported 30-day mortality, that varied from 4.1% in Australia/New Zealand to 9.2% in France. Across international registries, the number of hospitals varied from 10 to 224, with patient numbers ranging from 418 to almost 8000. The observation period ranged from 2007 to 2014, with some registries reporting results for a single year and others combining up to 5 years. Age was similar across all regstries, with the mean or median being consistently over 80 years. Most registries reported either the STS risk score or a Euroscore, rendering international comparisons difficult; only 3 registries reported both types. The median STS score for Québec was similar to that reported in the USA (6% [interquartile range, IQR: 4-9] vs 7% [IQR: 5-11], respectively). Rates of procedural success varied widely across regions, largely due to non-standardized classification of post-TAVI aortic regurgitation. Renal impairment, bleeding and transfusion were rarely reported and definitions varied. The most frequently reported quality indicators were conversion to surgery, in-hospital stroke, need for a new pacemaker and death. Conversion to surgery occurred in 2.7% in Québec and 0.4%-4.3% internationally. Incidence of in-hospital stroke was 2.2% for Québec and 1.6%-3.3% across registries. New pacemakers were required for 6.6% to 24.8% of patients in registries, and for 14.9% in Québec. In-hospital mortality in Québec was 6.5% versus 5.1% in Austria, 5.5% in USA, 7.3% in Spain, and, in Germany, 5.1% for transvascular and 7.7% for transapical TAVI. Some other registries only reported 30-day mortality, that varied from 4.1% in Australia/New Zealand to 9.2% in France. ConclusionPractice and outcomes of TAVI appear to vary widely across the world, due at least in part to lack of standardized reported outcomes and patient populations, and despite publication of recommended endpoints (VARC and BARC). While quality benchmarks for patient selection and outcomes remain unclear, continued monitoring with timely feedback to TAVI teams and decision-makers is essential for this new and costly intervention that is predominantly being performed in the very elderly. Practice and outcomes of TAVI appear to vary widely across the world, due at least in part to lack of standardized reported outcomes and patient populations, and despite publication of recommended endpoints (VARC and BARC). While quality benchmarks for patient selection and outcomes remain unclear, continued monitoring with timely feedback to TAVI teams and decision-makers is essential for this new and costly intervention that is predominantly being performed in the very elderly.

Our cardiology evaluation unit recommended to the Québec Ministry of Health that transcatheter aortic valve implantation (TAVI) be used in carefully selected patients and that use and outcomes be independently monitored. Herein, we describe the results of our province-wide field evaluation of patient and procedural characteristics and of clinical outcomes, and make comparisons with the USA Transcatheter Valve Therapy (TVT) registry. We conducted a retrospective review of medical charts of all TAVI cases (N=219) in 6 hospitals during April to December 2013. Variables, outcomes and definitions were chosen to enable valid comparisons with other registries in Canada and USA. During the 9-month period, the number of TAVI patients varied from 11 to 83 across the 6 Québec hospitals. Median age was 85 years (interquartile range [IQR]: 79-88) vs 84 years (IQR: 78-88) in the TVT registry. Half of Québec TAVI patients were women, as in TVT. The STS predicted risk of operative mortality was documented for 53% of patients with a median STS score of 6% (IQR: 4-9) compared to 7% (IQR: 5-11) in TVT. The transapical approach was used less often in Québec than in TVT (14% vs 29%). While only Edwards SAPIEN XT valves were used in the TVT registry, valves used in Québec were Edwards SAPIEN XT (69%), Medtronic Corevalve (27%) and Portico (3%). In-hospital mortality in Québec was 5.5% (95% CI: 2.4-8.5), identical to TVT (5.5%; 95% CI: 5.0-6.1). Conversion to surgery (2% vs 1%) and insertion of a new permanent pacemaker (14% vs 7%) were higher in Québec than in TVT. Patients in Québec spent less time in intensive care (median 32 hours, IQR: 24-73, vs 46 hours, IQR: 25-77) and in hospital after TAVI (median 5 days, IQR: 3-8, vs 6, IQR: 4-10) than in TVT. Québec patients were more likely to be discharged directly home than patients in TVT (79% vs 63%). Preliminary TAVI results for Québec are similar to those in the TVT registry. Notable differences in practice were use of valves other than SAPIEN XT, less documentation of STS-predicted mortality, less use of the transapical approach and more frequent need for permanent pacemakers. Some differences may relate to the greater variety of valve types used in Québec. In-hospital mortality was similar. Continued monitoring with timely feedback and long-term follow-up of outcomes, in collaboration with clinical experts, are essential to promote an optimal quality of care.

Treadmill tests are widely used for coronary artery disease (CAD) evaluation. When use in intermediate risk patients, it has a 70% specificity and sensibility to diagnose CAD. One of the most important prognostic factors is the maximal achievable workload, even in patients with known CAD. There is scarce data available to help decision-making for patients with an equivocal result but who can achieve a high workload (>11 METs). We aim to evaluate the added diagnostic value of a stress echocardiography for these patients.