PhD defence M.J.A.G (Marjo) de Ronde-Tillmans

Summary:

Aortic valve stenosis is a frequently occurring disease in the western hemisphere and is found predominantly in older patients over the age of 75. Until 2002 Surgical Aortic Valve 
Replacement (SAVR) was the treatment of choice for patients with severely symptomatic  Aortic Valve Stenosis (AS) although a significant number of these patients did not meet
the treatment criteria for SAVR due to high surgical risk and the presence of co-morbidities. However, in 2002 Prof. A. Cribier initiated a potential new option by treating the first patients with severe AS using an aortic heart valve implanted percutaneously through the groin approach; a trans-catheter aortic valve implantation (TAVI). In the following years, across the world, many more surgical high-risk patients (inoperable patients) were treated successfully using this percutaneous technique. The positive results of international randomized trials have led to an expansion in the indications for TAVI to include not only inoperable patients but also patients with AS and an acceptable surgical risk. Long term outcomes are important for patients with a low and medium surgical risk, as they often have a longer life expectancy than the high-risk patients. A recent study described that degeneration of an aortic valve prosthesis occurs more often in patients with severe symptomatic AS treated with a surgical bio-prothesis compared to those treated with a self-expandable trans-catheter valve. Although TAVI, due to its minimally invasive characteristics, offers many advantages compared to open heart surgery there are still some risks involved. At the start of the use of the technique these were mostly bleeding events, vascular complications, pacemaker implants, peri-valvular leaks and sometimes even deaths during or shortly after the procedure. These procedure related complications have been significantly reduced over time with the increased experience of the Multidisciplinairy Heart Team and operators combined with the continuous innovation of the technique and equipment, resulting in an improvement in outcomes of TAVI. The procedure itself has been technically significantly simplified over time, with it now taking place under local anesthetic with a minimally invasive access site resulting in quicker mobility and recovery and when possible, a shorter hospital stay. Together with these clinical and technical improvements, TAVI has also become a popular subject for scientific studies, contributing to the above-mentioned improvements. This thesis aims to also contribute to that.

The aim of this thesis is to provide an overview of the evolution of TAVI in the Erasmus MC since the first procedure in 2005, the implementation of the TAVI Care and Cure Program and the consequences on daily clinical practice. Central to this is the holistic approach to the individual patient with Aortic Valve stenosis, to determine the best treatment strategy for the patient taking into account the balance between risks and benefits to meet the patient’s expectations and outcome on quality of life after treatment. I have been actively involved in the setting up and further development of the percutaneous, Transcather Aortic Valve replacement (TAVI) program since the introduction and implementation of the first TAVI procedure in November 2005 in the Erasmus MC in Rotterdam, the Netherlands. Due to this, I have learnt a lot, both as a nurse and on a human level.