The current state of TAVI in Germany – a nationwide assessment

D. Grundmann (Hamburg)¹, W.-K. Kim (Gießen)², M. Abdel-Wahab (Leipzig)³, M. Adam (Köln)⁴, C. Frerker (Lübeck)⁵, L. Gaede (Erlangen)⁶, O. Husser (München)⁷, M. Knorr (Mainz)⁸, D. Leistner (Frankfurt am Main)⁹, C. Liebetrau (Frankfurt am Main)¹⁰, H. Möllmann (Dortmund)¹¹, E. Rafflenbeul (Hamburg)¹², M. Saad (Kiel)¹³, T. Schmitz (Essen)¹⁴, J.-M. Sinning (Köln)¹⁵, A. Wolf (Wuppertal)¹⁶, A. Ghanem (Hamburg)¹⁷, T. K. Rudolph (Bad Oeynhausen)¹⁸, M. Seiffert (Bochum)^19
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ²Universitätsklinikum Gießen und Marburg GmbH Medizinische Klinik I - Kardiologie und Angiologie Gießen, Deutschland; ³Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ⁴Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ⁵Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ⁶Friedrich-Alexander Universität Erlangen-Nürnberg Medizinische Klinik 2 Erlangen, Deutschland; ⁷Augustinum Klinik München Kardiologie und Intensivmedizin München, Deutschland; ⁸Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; ⁹Universitätsklinikum Frankfurt Med. Klinik III - Kardiologie, Angiologie Frankfurt am Main, Deutschland; ¹⁰Frankfurt am Main, Deutschland; ¹¹Kath. St. Paulus Gesellschaft Klinik für Innere Medizin I Dortmund, Deutschland; ¹²Schön Klinik Hamburg Eilbek Kardiologie Hamburg, Deutschland; ¹³Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; ¹⁴Elisabeth-Krankenhaus Essen GmbH Klinik für Kardiologie und Angiologie Essen, Deutschland; ¹⁵Cellitinnen Krankenhaus St. Vinzenz Köln Innere Medizin III - Kardiologie Köln, Deutschland; ¹⁶Helios Universitätsklinikum Wuppertal - Herzzentrum Medizinische Klinik 3 - Kardiologie Wuppertal, Deutschland; ¹⁷Asklepios Klinik Nord - Heidberg Abteilung für Kardiologie Hamburg, Deutschland; ¹⁸Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ¹⁹Berufsgenossenschaftlliches Universitätsklinikum Bergmannsheil gGmbH Medizinische Klinik II, Kardiologie und Angiologie Bochum, Deutschland

Background

The recent 2025 ESC guidelines for the management of valvular heart disease emphasize the role of transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis. Despite extensive scientific evidence for TAVI, many steps of the procedure or periprocedural management ultimately remain at the discretion of the operator due to a paucity of recommendations.

Aims:

To assess the routine procedural and periprocedural management of patients undergoing TAVI for the treatment of aortic stenosis in Germany.

Methods

The working group for interventional cardiology (AGIK) of the German Cardiac Society (DGK) designed an online survey that was distributed to all German TAVI centers to obtain a representative assessment of clinical practice. The questionnaire comprised a total of 68 questions covering pre-procedural planning, procedural strategies, the post-procedural course and structural aspects. Data were collected from October 2023 to June 2024.

Results 

The survey was completed by 61/85 centers (71.8%), representing a cumulative volume of approximately 20.000 procedures annually. Most centers (70%) performed 200 to 600 TAVI procedures per year. Preprocedural workup and procedural aspects differed: Coronary angiography remained routine in 76% of centers while transesophageal echocardiography was restricted to specific indications (86%). Analgosedation was the preferred anesthesia strategy (56%) followed by local anesthesia (24%). Transfemoral access was first-choice (93.4%), transaxillary (2.9%) and transapical (2.7%) approaches were selectively employed. Ultrasound-guided puncture was performed in 54% of cases with subsequent suture-based preclosure (67%). The preferred secondary access was femoral (57%). Cerebral embolic protection (<5% in 87% of centers), and direct left-ventricular pacing (9%) were limited to selected cases. Transcatheter heart valve selection was related to various factors, including calcification patterns (66%), annular dimensions (59%) and preservation of coronary access (51%). Final aortography (93%) and invasive hemodynamic assessment (71%) were considered standard by most respondents. Heparin was antagonized after conclusion of the procedure in most centers partially (42%) or completely (32%). Only 16% regularly transferred patients after uneventful TAVI to intensive care, the remainder to intermediate care or normal wards. Routine rhythm monitoring was performed for 1-2 days in 60% of centers. Aspirin was the standard antithrombotic drug after TAVI (93%) and DOAC monotherapy was preferred in patients with an indication for anticoagulation.

Conclusions

With the recent guideline-supported expansion of TAVI, this nationwide survey offers important insights into the current clinical routine and detailed (peri-)procedural steps of TAVI. These findings suggest a heterogenous approach to TAVI and may stimulate further discussions on workflow optimization to improve outcomes for patients with severe aortic stenosis.