South African TAVI Program adherence to ESC 2021 VHD Treatment Guidelines between 2022-2024

Abstract

The SHARE TAVI registry provides data of all TAVIs in South Africa for local quality improvement initiatives in the face of high healthcare resource constraints. The ESC 2021 Guidelines for VHD moved from using solely surgical risk scores to determine intervention, focusing more on age (<75 vs. >_75) and anatomical factors, with TAVR preferred for patients >75 years age, or High Risk (STS >8%) or unsuitable for SAVR based on clinical, anatomical and procedural factors at the decision of the Heart Team, and SAVR recommended for those at low surgical risk (age <75 years and STS <4%).

Between Jan 2022 and Dec 2025, 1868 patients with TAVI implants were entered into SHARE TAVI, at 31 sites nationally.

1531 (81.96%) met clear criteria for TAVI, 1459 were >75 years and 72 others were STS>8% but <75 years. 337 patients aged <75 years and had low to intermediate STS scores as seen in TABLE 1.

As seen in TABLE 2, of the 337 patients aged <75 years, 184 had low STS scores but very severe or severe AS gradient, adhering to Class IB guideline criteria for individual clinical characteristics of suitability for TAVI rather than surgery, at the decision of the Heart Team, and 85 patients had Intermediate STS Scores with moderate to very severe gradients, again within evidence category IB of the guidelines.

The 68/1868 remaining patients aged <75 years were individually analysed here for any further specified contraindications to surgery. 15 had no recorded STS Scores or Echo criteria recorded, or additional clinical notes, and could not be evaluated further for adherence to guideline criteria.

16/53 remaining low risk, moderate gradient patients had no recorded specified contraindications to surgery, the other 37 had clearly listed specific comorbidities or contraindications to surgery, thus fulfilling guideline criteria for inclusion in the TAVI program by Heart Team Decision according to Class IB evidence.

Conclusion

31/1868 (1.66%) patients over 3 years following publication of the ESC 2021 VHD treatment guidelines received TAVI without clearly recorded indications that TAVI would be more appropriate than SAVR according to Class IB evidence. Measurable criteria shared through local registries allow for quality improvement initiatives in patient selection given the economic restraints in healthcare, but this shows the great majority of TAVI patients in South Africa are being appropriately selected and there was excellent guideline uptake and adherence to the 2021 ESC guidelines.ESC 2026 Tables SHARE TAVI