1 EDITORIAL EuroIntervention 2014;10:0-0 DOI: 10.4244/EIJV10I5A0 © Europa Digital & Publishing 2014. All rights reserved. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 *Corresponding author: Department of Cardiology, Galway University Hospital, Newcastle Road, Galway, Ireland. E-mail: darrenmylotte@gmail.com TAVI at institutions without cardiovascular surgery departments: WHY? Darren Mylotte 1 *, MB, MD; Stuart J. Head 2 , PhD; Arie Pieter Kappetein 2 , MD, PhD; Nicolo Piazza 3 , MD, PhD 1. Department of Cardiology, Galway University Hospitals, Galway, Ireland; 2. Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands; 3. Department of Interventional Cardiology, McGill University Health Centre, Montreal, Quebec, Canada “Thou shall not”……unless “thou” is in Germany! The first commandment of transcatheter aortic valve implantation (TAVI) is that it should not be performed in the absence of an on- site cardiovascular surgery department. This position is enshrined in various recommendations and statements of national and inter- national cardiology societies 1-4 . Although seemingly pedantic, it is important to distinguish between an “on-site surgical department” and “on-site surgery”. For the purposes of TAVI, the latter insinu- ates availability of surgical “back-up” for vascular access and/or the management of procedural complications, while the former implies a far more substantial contribution to patient care. On-site cardio- vascular surgery departments optimise TAVI care by enhancing (1) patient selection and procedural planning, (2) procedural perfor- mance, and (3) management of complications and post-procedural care. In this month’s issue of EuroIntervention, Eggebrecht and col- leagues present an intriguing comparison of TAVI outcomes among patients treated either in hospitals without an on-site cardiovascular surgery department or in traditional medico-surgical centres 5 . The authors are to be congratulated for highlighting this controversial practice in Germany where, among 1,432 patients enrolled in the German TAVI registry, 178 (12%) were treated either in a typical medico-surgical centre by a visiting TAVI operator (n=129) or “off- site” in a non-surgical centre with a visiting surgical team (n=49). Theoretically, a TAVI operator visiting an existing medico-surgical site will benefit from the availability of the existing TAVI Heart Team, while an operator performing TAVI in an “off-site” non-sur- gical site will not. Statistical comparisons between groups are not presented, due to the high likelihood of selection bias, but the data presented suggest that patients treated “off-site” were a less chal- lenging cohort, which had protracted procedures yet similar clini- cal outcomes to TAVI recipients from traditional medico-surgical centres. It is intriguing to examine the motives behind the development of this novel treatment pathway. Potential advantages of “off-site” TAVI include the provision of a more expedient, familiar and local- ised service for the patient, and the development of new skills ben- efiting the physician and/or parent institution. In geographically isolated areas or in healthcare systems where access to TAVI may be restricted by geographic location, such benefits are amplified. Germany is not such a healthcare system 6 , and therefore one must consider personal or institutional financial gain, prestige, or other such motives for the emergence of this practice pattern. Centralisation of care for high-risk patients and complex inter- ventions is recommended based on accumulating evidence of lower patient mortality associated with high-volume institution care across multiple clinical conditions and care settings 7-9 . Luft described this effect as the “practice-makes-perfect hypothesis” 9 .