Tese de Doutoramento Medicina 2023 Faculdade de Ciências Médicas, Universidade NOVA de Lisboa

Cardiovascular diseases (CVDs) are the leading causes of death and hospitalization and represent an enormous clinical and public health burden, which disproportionately affects older adults. According to the Instituto Nacional de Estatística (INE), life-expectancy at born and at 65 years has increased, respectively, 9,6% (73,93 to 81,06 years) and 5,1% (80,60 to 84,69 years), between 1990 and 2020. This evolution is observed worldwide and the World Health Organization (WHO) expects octogenarians to quadruple to 396 million by 2050. The 2060 INE estimates for life expectancy at born in Portugal are 84,21 years for men and 89,88 years for women1,2. This has increased the relative importance of heart valve diseases whose prevalence reached more than one in every ten octogenarians. This document summarizes a coherent professional path dedicated to the cardiovascular area, marked by the search for professional excellence, based on solid evidence-based clinical experience, phased research and the constant challenge of technical-scientific evolution. In the following pages, you will find the testimony of the drastic change caused by the structural cardiac intervention model in the aortic valve, with consequences in the organization and training of cath labs, as well as in the entire Cardiology department in terms of care and investigations. Before becoming a cardiologist, I intended already to be an interventional cardiologist and it was with the formulation of this question that I first addressed Prof. Dr. Ricardo Seabra-Gomes, in 1996. His provocative answer has since then placed the responsibility over my shoulders by the success, or not, of this ambition. The endeavor was, and still is, extremely demanding - no more than for everyone - and guided by the critical spirit of the tutored clinical activity in the light of emerging evidence-based medicine. Hospital de Santa Cruz is a pioneer unit in several techniques and percutaneous coronary intervention assumed dominance in 1990, when it surpassed, in number, surgical myocardial revascularization. In 2008 the Cardiology Director, Dr. Aniceto Silva, accepted my proposal for the organization, structuring and development of a program based on the individualized approach of each patient, using all types of percutaneous and other techniques - and all sorts of devices. Thus, it was born the Percutaneous Valves (VaP) program, transversal between Cardiology and Cardiac Surgery, encompassing referral, assessment, patient study, multidisciplinary meetings, discharge and follow-up during the consultation. Parallel and progressively, there was a strong pedagogical and training project to endow the team with a critical mass that allowed the senior operators to achieve autonomy and transversal competence, like that of coronary intervention, unique in the national reality. Finally, several international research consortia were conquered and integrated, in parallel with the international path followed that culminates in the prestigious Board of the European Association of Interventional Cardiology (EAPCI). Safety and efficacy have always been the first requirements for any cardiovascular technique, because mortality and complications are extremely important from a clinical point of view, resulting in prolonged admission and increased hospital costs. Coordinating the structural program is an enormous challenge that intersects all professional groups and colleagues, from resident to the cardiology head, highlighting the importance of building and caring for the referral network. It essentially went through four phases, each requiring an adaptation of the clinical, organizational, research, communication and management strategic plan: I. From 2008 to 2013, the technical and device launch phase, with a concentration of the volume on the three most experienced operators, intensive use of imaging and general anesthesia as default; II. From 2014 to 2016, the strategic innovation and sustained growth phase, with the expansion of the team to other senior operators, with the use of new techniques and devices - including mitral valves - with the cautious introduction of more simplified protocols for TAVI anesthesia and replication of image expertise to non-aortic space. The institution became a national leader and the period includes an official institutional survey that creates waiting lists in 2015 and provides a growth opportunity. The Presidency of Associação Portuguesa de Cardiologia de Intervenção (APIC) poses challenges and provides national and international collaborative opportunities that were distant, until then; III. From 2016 to 2017, the accelerated growth phase to respond to waiting lists and achieve maturation in the entire structural field. The visit of similar institutions is carried out with the adoption of an innovative model of sedation-analgesia with the support of anesthesiology, the teaching of the technique to all senior operators as well as the simplification of intra-hospital processes. The space of transseptal techniques enlarges and with it, all the imaging knowledge. Integration into EAPCI's European Valve For Live project projects APIC into EAPCI. The invitation to join its Board is challenging and allows you to competitively integrate prestigious European and North American research consortia. IV. From 2018 onwards, the consolidation phase, that is based on the daily routine of structural intervention techniques, with underlying administrative coordination and the implementation of a long-distance program that concentrates clinical examinations and evaluations in a single day. There is a growing and unique transversal experience that makes the center the Iberian leader in TAVI and that makes it a hands-on training center for other centers such as Centro Hospitalar do Funchal and Centro Hospitalar da Universidade de Coimbra, in addition to very important care partnerships with the Hospital Garcia de Orta, Hospital Fernando da Fonseca and Centro Hospitalar de Leiria. The biggest current challenge is to provide our network with a simple, expeditious and efficient articulation, expanding the center's narrative to the area of quality from the perspective of the patient and the referrer, based on scientific research within the scope of consortia. Other challenges, such as percutaneous mitral and tricuspid valve intervention, closure of the left atrial appendage and percutaneous closure of valve leaks, arise from this maturity and become a natural evolution in the field of percutaneous structural interventions