Transcatheter Aortic Valve Implantation: Assessing the Learning Curve
What is the learning curve for transfemoral transcatheter aortic valve implantation (TAVI)?
The authors assessed the outcome of the first 44 consecutive patients who underwent transcatheter aortic valve implantation as part of the PARTNER (Placement of Aortic Transcatheter Valves) trial at a single institution between November 2008 and May 2011. Patients were divided into three groups based on the sequence of the procedure.
The overall mortality was 11%. There was a significant improvement in procedural variables across the three tertiles. The total amount of contrast used decreased from 180 ml to 160 ml to 130 ml, while the valvuloplasty to valve deployment time decreased from 12.0 minutes to 11.6 minutes to 7.0 minutes (p < 0.001). Fluoroscopy time decreased from 26.1 minute to 17.2 minutes to 14.3 minutes (p < 0.001) with a corresponding significant decrease in radiation dose.
The authors concluded that there is a powerful learning curve for TAVI, with plateauing of proficiency after 30 cases.
A learning curve has been demonstrated for most procedures, and TAVI is no exception. TAVI involves a multidisciplinary approach, and the learning curve relates to the increasing proficiency of the operator as well as the entire team. The authors suggest that learning plateaus after 30 cases, but this may be related to the small size of the study cohort and the unique environment of their institution. Other studies have demonstrated steadily improving outcomes beyond this threshold (Catheter Cardiovasc Interv 2011;78:977-84), and further studies are warranted to assess the appropriate thresholds for credentialing and maintenance of skill.
Keywords: Fluoroscopy, Credentialing, Learning Curve, Catheters, Heart Valve Prosthesis Implantation, Angioplasty, Radiation Dosage, Laparoscopy
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