# The implementation of a streamlined TAVI patient pathway across five European countries: BENCHMARK registry

Francesco Saia, Sandra Lauck, Eric Durand, Douglas F Muir, Mark Spence, Mariuca Vasa-Nicotera, David Wood, Cristóbal A Urbano-Carrillo, Damien Bouchayer, Vlad Anton Iliescu, et al.

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Francesco Saia, Sandra Lauck, Eric Durand, Douglas F Muir, Mark Spence, et al. The implementation of a streamlined TAVI patient pathway across five European countries: BENCHMARK registry. Clinical Research in Cardiology, 2025, 10.1007/s00392-025-02638-z. hal-05067535

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# The implementation of a streamlined TAVI patient pathway across five European countries: BENCHMARK registry

Francesco Saia¹ · Sandra Lauck² · Eric Durand³ · Douglas F. Muir⁴ · Mark Spence⁵ · Mariuca Vasa-Nicotera⁶ ·

David Wood² · Cristóbal A. Urbano-Carrillo⁷ · Damien Bouchayer⁸ · Vlad Anton Iliescu⁹ · Christophe Saint Etienne¹⁰ ·

Florence Leclercq¹¹ · Vincent Auffret¹² · Lluis Asmarats¹³ · Carlo Di Mario¹⁴ · Aurelie Veugeois¹⁵ ·

Jiri Maly¹⁶ · Andreas Schober¹⁷ · Luis Nombela-Franco¹⁸ · Nikos Werner¹⁹ · Joan Antoni Gómez-Hospital²⁰ ·

Julia Mascherbauer²¹ · Giuseppe Musumeci²² · Nicolas Meneveau²³ · Thibaud Meurice²⁴ · Felix Mahfoud²⁵ ·

Federico De Marco²⁶ · Tim Seidler²⁷,²⁸ · Florian Leuschner²⁹ · Patrick Joly³⁰ · Jean Philippe Collet³¹ ·

Ferdinand Vogt³²,³³ · Emilio Di Lorenzo³⁴ · Elmar Kuhn³⁵ · Vicente Peral Disdier³⁶,³⁷ · Gemma McCalmont³⁸ ·

Radka Rakova³⁸ · Wilbert Wesselink³⁸ · Jana Kurucova³⁸ · Violetta Hachaturyan³⁹ · Claudia M. Lüske³⁹ ·

Peter Bramlage³⁹>Dek Frank⁴⁰,⁴¹ for the BENCHMARK Investigator Group

Received: 30 July 2024 / Accepted: 14 March 2025
© The Author(s) 2025

## Abstract

**Background** Benchmark best practices have been shown to streamline the clinical pathway for patients undergoing tran-scatheter aortic valve implantation (TAVI), but the impact in diverse health systems is unknown.

**Aims** We evaluated the impact of Benchmark best practices implementation in Germany, Austria, France, Spain, and Italy.

**Methods** International, multicentre registry of severe symptomatic aortic stenosis (AS) patients undergoing TAVI with a balloon-expandable valve, before and after Benchmark best practices implementation. Objectives were to reduce overall and intensive care unit (ICU) length of stay (LoS), and to document 30-day safety.

**Results** A total of 890 patients were analysed in France, 454 in Spain, 362 in Germany, 300 in Italy, and 176 in Austria. Patients had the highest surgical risk in Germany (EuroSCORE II 6.8 ± 7.3%) and lowest in Spain (3.8 ± 2.6%). Austrian patients reported higher rates of prior myocardial infarction, severe pulmonary hypertension, and aortic valve-related symptoms at baseline. After the implementation of Benchmark best practices, the median hospital LoS was significantly reduced in France (5 vs. 3 days, *p* < 0.001), Spain (6 vs. 4, *p* < 0.001), Germany (9 vs. 6, *p* < 0.001), and Italy (7 vs. 5, *p* < 0.001); reductions in median ICU LoS were reported in France (1.1 vs. 0 days, *p* < 0.001), Spain (1.9 vs. 1, *p* < 0.001), and Germany (1 vs. 0.9, *p* = 0.004). Across all countries, 30-day safety outcomes were uncompromised and reduced rates of major vascular complications rates were observed in Germany (5.9 vs. 0.0%, *p* < 0.001).

**Conclusion** The implementation of Benchmark best practices in diverse European healthcare systems resulted in reduced hospital and ICU LoS without compromising patient safety.

**Trial registration** ClinicalTrials.gov NCT04579445, September 28th, 2020

**Keywords** Aortic stenosis · Quality of care · Prospective registry · Transcatheter aortic valve implantation · TAVI · Clinical care

## Introduction

Since the first-in-human transcatheter aortic valve implantation (TAVI) in 2002 in Europe, the procedure has been rapidly adopted outnumbering surgical aortic valve replacement (SAVR), with a predicted further sharp increase due to expanding indications and an ageing population [1, 2]. Currently, an estimated 115,000 candidates are eligible for

Jean Philippe Collet deceased on December 15th, 2023.

Extended author information available on the last page of the article
TAVI per year in Europe alone, with the highest rates predicted in Germany (20,466 candidates), followed by Italy (15,784 candidates), France (14,632 candidates), and Spain (10,274 candidates) [3]. The European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) guidelines for the management of valvular heart disease provide detailed guidance on decision-making, including accurate diagnosis, risk assessment, as well as timing and indication for the most suitable type of intervention(s) [4]. However, there are currently no consensus recommendations on how to streamline the patient pathway to optimize timely access to care and mitigate the risks of in-hospital complications [5]. Given the steep increase in aortic stenosis (AS) prevalence and existing variation in regional strategies related to healthcare resources, pre-procedural planning, and patient management, there is a need for a comprehensive approach to standardize quality of care delivered to patients undergoing TAVI.

The European FAST-TAVI (Feasibility And Safety of Early Discharge After Transfemoral [TF] Transcatheter Aortic Valve Implantation) project has previously shown that the use of pre-specified risk criteria effectively guided the timing of discharge and is associated with 1-year safety [6, 7]. In addition, the implementation of a clinical valve coordinator or TAVI nurse led to improved discharge management and increased patient satisfaction without compromising safety [8]. This initiative built on the minimalist Vancouver 3M (multidisciplinary, multimodality but minimalist) Clinical Pathway approach was introduced to standardize care and reduce hospital length of stay (LoS) [9]. The process includes risk-stratified pre- and peri-procedural practices, post-procedure care with early mobilization and reconditioning, and a criteria-driven discharge algorithm.

In this context, the objective of the BENCHMARK registry was to measure the impact of eight best practices on LoS (admission to discharge), duration of critical care, and patient satisfaction with uncompromised patient safety in diverse European countries. At 30 days, the standardized implementation of Benchmark was safe and reduced total hospital and critical care LoS [10].

## Methods/design

BENCHMARK (ClinicalTrials Identifier: NCT04579445) is a multicentre, international study of patients with severe symptomatic AS undergoing TAVI at 28 centres across Europe including Austria, France, Germany, Italy, Czech Republic, Romania, and Spain [11]. For the current analysis, the Czech Republic and Romania were excluded due to low enrolment in single centres. Benchmark was conducted according to the European Medical Device Regulations, the International Organization for Standardization (ISO

14155:2020), and the Declaration of Helsinki. The registry was approved by the independent ethics review boards of participating sites and patients provided written informed consent.

## Patient selection

Between January 2020 and March 2023, the BENCHMARK registry documented a total of 2388 patients. Patients were enrolled retrospectively prior to, and prospectively after the introduction of the Benchmark best practices. Key inclusion criteria were transfemoral TAVI with a balloon-expandable valve, 18 years and older, and scheduled for 30-day and 1-year follow-up visits. Patients were excluded if they were undergoing valve-in-valve procedures, were pregnant, or for whom key variables for the assessment were missing in the retrospective cohort.

## Benchmark best practices

The development of eight best practices was informed by contemporary evidence and expert clinical opinions[12] and included (1) education of patient and family; (2) determination of anticipated discharge date at admission based on pre-procedural risk stratification and scheduling of post-procedural diagnostics; (3) echocardiographic- or angiographic check at the end of the procedure immediately performed to confirm vascular access closure and absence of peri-procedural complications; (4) nurse-led early mobilization protocol; (5) use of decision tree to determine the need for new pacemaker if required without increasing hospital stay; (6) criteria-based safe discharge home; (7) daily visit by implanting physician and interaction with the rest of the team; and (8) education and alignment of the internal team (medical, nursing, and paramedical). The detailed implementation process, including the education of centres and local planning, has been previously described elsewhere [11].

## Study end points

The reduction in the total hospital LoS (from admission to discharge) and the duration of critical care admission (defined as ICU, cardiac/coronary care unit [CCU] or intermediate care [IMC]) were the primary end points. Secondary objectives included the assessment of procedural success and complications and patient safety at 30 days. While the overall Benchmark programme was powered to ascertain the safety of patients, the comparison of outcomes prior to and following Benchmark implementation across five countries is exploratory.

<figure><img src="image_2.png" /></figure>
## Statistical analysis

All available patient data were analysed and missing data were not imputed. Continuous variables were presented as mean ± standard deviation (SD) or median and interquartile ranges (IQR). The Kolmogorov-Smirnov test was used to test for normal distribution. Categorical variables were reported as frequencies and percentages. All analyses were performed using IBM SPSS Statistics version 29 (IBM, Armonk, New York) or R Core Team (https://www.R-project.org/).

## Results

A total of 890 patients in France, 454 in Spain, 362 in Germany, 300 in Italy, and 176 in Austria were included. The implementation rates of Benchmark best practices by country are provided in Supplementary Fig. 1. Baseline patient characteristics by country prior and after the implementation of Benchmark are provided in Supplementary Table 1. The detailed results for each country are presented below.

## France

Patients in France reported the lowest rates of aortic valve-related symptoms at baseline, including dizziness (6.4%), (pre-) syncope (6.0%), and Canadian Cardiovascular Society (CCS) angina class 3/4 (2.1%) (Table 1). Patients treated in France tended to have less comorbid conditions, including prior myocardial infarction (10.5%) and severe pulmonary hypertension (3.5%). Nevertheless, the aorto-ventricular mean pressure gradient (PG) was highest in the French cohort (47.2 ± 12.8 mmHg) (Table 2).

After the implementation of Benchmark, French patients received local anaesthesia (LA) with minimal sedation or anxiolytic more often and had the shortest intervention time (median [interquartile range (IQR)] 55.0 [45.0, 70.5]), but had the highest rates of perioperative permanent pacemaker implantations (8.4%) compared to other countries (Table 3). There was a significant reduction in the hospital LoS in France after the implementation of Benchmark (from median 5.0 to 3.0 days, 40.0% decrease; *p* < 0.001) (Fig. 1A). At baseline, LoS in critical care was one of the highest in France (median 1.1 days) compared to other countries. After

<table><caption>**Table 1** Patient characteristics in the total patient population by country</caption><thead><tr><th>Characteristic, n (%) or mean ± SD or median (IQR)</th><th>France (890 pts, 9 sites)</th><th>Spain (454 pts, 5 sites)</th><th>Germany (362 pts, 6 sites)</th><th>Italy (300 pts, 4 sites)</th><th>Austria (176 pts, 2 sites)</th><th>p value</th></tr></thead><tbody><tr><td>Age (years)</td><td>80.1 ± 7.0<br>81.0 (76.0, 85.0)</td><td>80.7 ± 6.4<br>81.0 (77.0, 85.0)</td><td>79.6 ± 6.6<br>81.0 (76.0, 84.0)</td><td>81.6 ± 4.9<br>82.0 (79.0, 85.0)</td><td>80.1 ± 6.4<br>81.0 (77.8, 84.0)</td><td>&lt;0.001</td></tr><tr><td>Female gender</td><td>344 (38.9)</td><td>189 (41.6)</td><td>133 (36.7)</td><td>132 (45.8)</td><td>61 (34.7)</td><td>0.070</td></tr><tr><td>Body mass index (kg/m²)</td><td>27.6 ± 5.1<br>27.0 (24.2, 30.5)</td><td>28.0 ± 5.3<br>27.4 (24.7, 30.4)</td><td>27.1 ± 4.5<br>26.6 (24.1, 29.7)</td><td>26.8 ± 4.5<br>26.5 (23.5, 29.1)</td><td>27.9 ± 4.8<br>27.0 (24.7, 30.5)</td><td>0.008</td></tr><tr><td>Aortic valve-related symptoms</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Dizziness with exertion</td><td>56 (6.4)</td><td>228 (50.2)</td><td>62 (17.1)</td><td>60 (21.5)</td><td>112 (63.6)</td><td>&lt;0.001</td></tr><tr><td>(Pre-)syncope</td><td>52 (6.0)</td><td>53 (11.7)</td><td>40 (11.0)</td><td>31 (11.1)</td><td>28 (15.9)</td><td>&lt;0.001</td></tr><tr><td>NYHA class III or IV</td><td>443 (50.8)</td><td>262 (57.7)</td><td>233 (64.9)</td><td>171 (61.3)</td><td>107 (60.8)</td><td>&lt;0.001</td></tr><tr><td>Angina CCS 3 or 4</td><td>19 (2.2)</td><td>17 (3.7)</td><td>15 (4.2)</td><td>24 (8.6)</td><td>21 (11.9)</td><td>&lt;0.001</td></tr><tr><td>Risk scores and frailty</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>EuroSCORE II</td><td>4.6 ± 6.5<br>2.4 (1.6, 5.0)</td><td>3.8 ± 2.6<br>3.4 (2.0, 4.3)</td><td>6.8 ± 7.3<br>4.3 (2.1, 8.1)</td><td>6.0 ± 6.5<br>3.5 (2.2, 6.8)</td><td>4.0 ± 3.8<br>2.8 (1.8, 4.7)</td><td>&lt;0.001</td></tr><tr><td>Frailty, severe</td><td>11 (1.3)</td><td>29 (6.4)</td><td>19 (5.2)</td><td>5 (1.8)</td><td>4 (2.3)</td><td>&lt;0.001</td></tr><tr><td>Impaired mobility</td><td>52 (5.9)</td><td>76 (16.7)</td><td>100 (27.6)</td><td>14 (5.0)</td><td>30 (17.0)</td><td>&lt;0.001</td></tr><tr><td>Cognitive deficit</td><td>20 (2.3)</td><td>23 (5.1)</td><td>17 (4.7)</td><td>10 (3.6)</td><td>6 (3.4)</td><td>0.070</td></tr><tr><td>Comorbidities</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Prior MI</td><td>92 (10.5)</td><td>79 (17.4)</td><td>42 (11.6)</td><td>37 (13.2)</td><td>51 (29.0)</td><td>&lt;0.001</td></tr><tr><td>Peripheral artery disease</td><td>165 (18.8)</td><td>43 (9.5)</td><td>31 (8.6)</td><td>57 (20.3)</td><td>31 (17.6)</td><td>&lt;0.001</td></tr><tr><td>Diabetes mellitus</td><td>229 (26.1)</td><td>194 (42.7)</td><td>111 (30.7)</td><td>75 (26.7)</td><td>65 (36.9)</td><td>&lt;0.001</td></tr><tr><td>PH, severe<sup>a</sup></td><td>26 (3.5)</td><td>30 (7.2)</td><td>31 (8.8)</td><td>17 (7.2)</td><td>21 (15.4)</td><td>&lt;0.001</td></tr><tr><td>Renal insufficiency</td><td>225 (25.5)</td><td>107 (23.6)</td><td>95 (26.2)</td><td>87 (31.0)</td><td>51 (29.0)</td><td>0.213</td></tr><tr><td>Prior pacemaker</td><td>53 (6.3)</td><td>31 (6.8)</td><td>27 (7.7)</td><td>12 (4.4)</td><td>14 (8.1)</td><td>0.445</td></tr></tbody></table>

CCS Canadian Cardiovascular Society, *IQR* interquartile range, *MI* myocardial infarction, *NYHA* New York Heart Association, *SD* standard deviation, *pts* patients, *PH* pulmonary hypertension

<footnote><sup>a</sup>Mean pulmonary arterial pressure > 55 mmHg</footnote>
<table><caption>**Table 2** Electrocardiogram and echocardiography in the total patient population by country</caption><thead><tr><th>Characteristic, n (%) or mean ± SD<br>or median (IQR)</th><th>France<br>(883 pts, 9 sites)</th><th>Spain<br>(454 pts, 5 sites)</th><th>Germany<br>(362 pts, 6 sites)</th><th>Italy<br>(287 pts, 4 sites)</th><th>Austria<br>(176 pts, 2 sites)</th><th>p value</th></tr></thead><tbody><tr><td><strong>Electrocardiogram</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Rhythm</td><td></td><td></td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Sinus rhythm</td><td>657 (77.8)</td><td>325 (71.7)</td><td>248 (70.5)</td><td>216 (78.5)</td><td>101 (58.4)</td><td></td></tr><tr><td>Atrial fibrillation</td><td>125 (14.8)</td><td>97 (21.4)</td><td>74 (21.0)</td><td>44 (16.0)</td><td>50 (28.9)</td><td></td></tr><tr><td>Pacemaker rhythm</td><td>53 (6.3)</td><td>31 (6.8)</td><td>27 (7.7)</td><td>12 (4.4)</td><td>14 (8.1)</td><td></td></tr><tr><td>Other</td><td>10 (1.2)</td><td>0 (0.0)</td><td>3 (0.9)</td><td>3 (1.1)</td><td>8 (4.6)</td><td></td></tr><tr><td>AV block second or third degree</td><td>4 (0.5)</td><td>6 (1.3)</td><td>3 (0.9)</td><td>2 (0.7)</td><td>1 (0.6)</td><td>0.544</td></tr><tr><td>Left bundle branch block</td><td>85 (10.0)</td><td>53 (11.7)</td><td>42 (11.9)</td><td>27 (9.8)</td><td>31 (17.9)</td><td>0.046</td></tr><tr><td>Right bundle branch block</td><td>116 (13.7)</td><td>48 (10.6)</td><td>37 (10.5)</td><td>34 (12.4)</td><td>14 (8.1)</td><td>0.168</td></tr><tr><td><strong>Echocardiography</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>LVEF &lt; 50%</td><td>106 (12.5)</td><td>53 (11.7)</td><td>84 (24.6)</td><td>42 (14.8)</td><td>51 (29.0)</td><td>&lt;0.001</td></tr><tr><td>AR, mod/severe</td><td>122 (14.9)</td><td>54 (11.9)</td><td>56 (16.4)</td><td>43 (15.2)</td><td>12 (6.8)</td><td>0.020</td></tr><tr><td>AV mean PG (mmHg)</td><td>47.2 ± 12.8<br>45.0 (41.0, 53.0)</td><td>45.3 ± 11.8<br>44.5 (40.0, 51.0)</td><td>43.1 ± 16.4<br>41.0 (32.3, 53.0)</td><td>46.0 ± 13.6<br>44.0 (39.0, 53.0)</td><td>42.6 ± 14.0<br>41.5 (34.0, 48.8)</td><td>&lt;0.001</td></tr><tr><td>AV peak PG (mmHg)</td><td>71.6 ± 18.3<br>70.0 (61.0, 81.0)</td><td>74.6 ± 18.3<br>73.5 (65.0, 83.0)</td><td>69.5 ± 24.1<br>66.5 (54.0, 85.0)</td><td>72.8 ± 19.2<br>71.0 (62.5, 82.0)</td><td>71.3 ± 20.5<br>70.0 (60.0, 80.0)</td><td>&lt;0.001</td></tr><tr><td>V<sub>max</sub> (m/s)</td><td>4.1 ± 0.9<br>4.2 (3.9, 4.5)</td><td>4.3 ± 0.6<br>4.4 (4.1, 4.7)</td><td>4.0 ± 0.8<br>4.0 (3.6, 4.4)</td><td>4.2 ± 0.8<br>4.2 (4.0, 4.5)</td><td>4.2 ± 0.6<br>4.2 (3.9, 4.4)</td><td>&lt;0.001</td></tr><tr><td>AVA (cm<sup>2</sup>)</td><td>0.8 ± 0.4<br>0.8 (0.6, 0.9)</td><td>0.8 ± 0.2<br>0.7 (0.6, 0.9)</td><td>0.7 ± 0.2<br>0.7 (0.6, 0.9)</td><td>0.7 ± 0.2<br>0.8 (0.6, 0.9)</td><td>0.8 ± 0.2<br>0.7 (0.6, 0.9)</td><td>0.002</td></tr><tr><td>Indexed AVA (cm<sup>2</sup>/m<sup>2</sup>)</td><td>0.4 ± 0.2<br>0.4 (0.4, 0.5)</td><td>0.4 ± 0.1<br>0.4 (0.4, 0.5)</td><td>0.4 ± 0.1<br>0.4 (0.3, 0.5)</td><td>0.4 ± 0.1<br>0.4 (0.3, 0.5)</td><td>0.4 ± 0.1<br>0.4 (0.3, 0.5)</td><td>&lt;0.001</td></tr></tbody></table>

AR aortic regurgitation, AV aortic valve, AVA aortic valve area, IQR interquartile range, LVEF left ventricular ejection fraction, PG pressure gradient, SD standard deviation, pts patients

Benchmark implementation, France reported the highest reduction in the ICU/CCU/IMC LoS (from median 1.2 to 0 days (mean 2.1 to 1.1 days); *p* < 0.001) (Fig. 1B). Overall, the rates of complications at 30 days were low in France and remained unchanged before or after implementation of Benchmark (Table 4).

## Spain

The highest body mass index (BMI, 28.0 ± 5.3 kg/m²) and rate of diabetes mellitus (42.7%) were reported in Spain (Table 1). Nevertheless, the Spanish cohort had the lowest reported surgical risk (EuroSCORE II 3.8 ± 2.6%). Echocardiographic data reported that patients treated in Spain had the highest mean aorto-ventricular peak PG (74.6 ± 18.3 mmHg) and AV maximal velocity (Vmax, 4.3 ± 0.6 m/s) (Table 2).

Peri-procedural deep sedation was routinely used for many patients in Spain (39.7%), in contrast to other countries, where more than 90% of patients received local anaesthesia with or without conscious sedation; vascular injury rates were also comparatively higher in Spain (6.1%) (Table 3). Spain also documented one of the longest procedure (median [IQR] 70.0 [50.0, 85.0 min]) and intervention

(median [IQR] 100.0 [80.0, 125.0] min) times. The hospital LoS was significantly reduced in Spain following Benchmark (from median 6 to 4 days, 33.0% decrease; *p* < 0.001) (Fig. 1A). Similar to France, Spain initially reported the longest stay in critical care, which significantly decreased after the introduction of Benchmark (from median 1.9 to 1 day, 47.4% decrease; *p* < 0.001) (Fig. 1B). At 30 days, the rates of clinical events did not significantly change after the implementation of Benchmark (Table 4).

## Germany

Patients in Germany were characterized by a highly symptomatic presentation (NYHA class III/IV 64.9%), impaired mobility (27.6%), and the highest surgical risk (EuroSCORE II 6.8 ± 7.3%) at baseline (Table 1). The incidence of reduced left ventricular ejection fraction (LVEF < 50%) was high in the German cohort (24.6%) compared to France (12.5%), Spain (11.7%), and Italy (14.8%) (Table 2). Patients received LA without sedation or anxiolytic more often (17.7%) and had the lowest rate of intraprocedural bleeding complications (0.4%) (Table 3). Germany reported the longest hospital LoS prior to Benchmark and achieved the largest decrease after the implementation of Benchmark (from median 9.0 to 6.0 days, 33.0% decrease;
<table><caption>**Table 3** Procedural details and outcomes post-Benchmark implementation by country</caption><thead><tr><th>Characteristic, n (%) or mean ± SD or median (IQR)</th><th>France (568 pts, 9 sites)</th><th>Spain (248 pts, 5 sites)</th><th>Germany (235 pts, 6 sites)</th><th>Italy (202 pts, 4 sites)</th><th>Austria (109 pts, 2 sites)</th><th>p value</th></tr></thead><tbody><tr><td>Local anaesthesia (LA) ± conscious sedation</td><td>544 (96.8)</td><td>224 (90.3)</td><td>231 (98.3)</td><td>177 (96.7)</td><td>104 (95.4)</td><td>&lt;0.001</td></tr><tr><td>LA w/o sedation/anxiolytic</td><td>76 (13.6)</td><td>2 (0.8)</td><td>41 (17.4)</td><td>18 (9.9)</td><td>0 (0.0)</td><td></td></tr><tr><td>LA + minimal sedation/anxiolytic</td><td>292 (52.1)</td><td>98 (39.7)</td><td>94 (40.0)</td><td>87 (47.8)</td><td>1 (0.9)</td><td></td></tr><tr><td>LA + moderate sedation</td><td>173 (30.9)</td><td>25 (10.1)</td><td>84 (35.7)</td><td>67 (36.8)</td><td>103 (94.5)</td><td></td></tr><tr><td>Deep sedation</td><td>1 (0.2)</td><td>98 (39.7)</td><td>12 (5.1)</td><td>4 (2.2)</td><td>0 (0.0)</td><td></td></tr><tr><td>Procedural information</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Total procedure time</td><td>46.2 ± 23.2<br>40.0 (30.0, 55.0)</td><td>73.0 ± 31.1<br>70.0 (50.0, 85.0)</td><td>46.4 ± 22.1<br>40.0 (32.0, 55.0)</td><td>87.4 ± 38.1<br>77.5 (60.0, 100.0)</td><td>41.5 ± 23.7<br>37.0 (24.0, 48.8)</td><td>&lt;0.001</td></tr><tr><td>Intervention time</td><td>63.9 ± 31.5<br>55.0 (45.0, 70.5)</td><td>106.3 ± 40.6<br>100.0 (80.0, 125.0)</td><td>88.7 ± 30.0<br>90.0 (65.0, 106.0)</td><td>111.6 ± 36.3<br>105.0 (90.0, 130.0)</td><td>80.4 ± 35.7<br>80.0 (46.0, 110.0)</td><td>&lt;0.001</td></tr><tr><td>Procedural success</td><td>546 (98.6)</td><td>247 (100.0)</td><td>229 (97.4)</td><td>180 (100.0)</td><td>109 (100.0)</td><td>0.017</td></tr><tr><td>Complications</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Second valve needed</td><td>4 (0.7)</td><td>0 (0.0)</td><td>2 (0.9)</td><td>0 (0.0)</td><td>0 (0.0)</td><td>0.528</td></tr><tr><td>Permanent pacemaker implantation</td><td>47 (8.4)</td><td>14 (5.6)</td><td>7 (3.0)</td><td>7 (3.8)</td><td>1 (0.9)</td><td>0.002</td></tr><tr><td>Conversion to conventional surgery</td><td>3 (0.5)</td><td>0 (0.0)</td><td>2 (0.9)</td><td>0 (0.0)</td><td>0 (0.0)</td><td>0.657</td></tr><tr><td>Bleeding<sup>a</sup></td><td>9 (1.6)</td><td>15 (6.1)</td><td>1 (0.4)</td><td>3 (1.8)</td><td>1 (0.9)</td><td>0.002</td></tr></tbody></table>

IQR interquartile range, LA local anaesthesia, SD standard deviation, pts patients

p < 0.001), while critical care LoS was also significantly reduced (from median 1 to 0.9 days, 10.0% decrease; p = 0.004) (Fig. 1A and B). Furthermore, the implementation of Benchmark resulted in lower rates of major vascular complications at 30 days (5.9 vs 0.0%, p < 0.001) (Table 4).

### Italy

Italian patients had a high surgical risk (EuroSCORE II 6.0 ± 6.5%) and presented with higher rates of cardiac symptoms (NYHA class III/IV: 21.5%) and peripheral arterial disease (20.3%) compared to other cohorts. In contrast, their rate of impaired mobility was lowest (5.0%) (Table 1). Italian patients had the longest procedure (median [IQR] 77.5 [60.0, 100.0] min) and intervention times (median [IQR] 105 [90.0, 130.0] min) (Table 3). In Italy, there was a significant reduction in the median hospital LoS after the implementation of Benchmark (7 to 5 days, 29.0% decrease; p < 0.001), although the LoS in ICU/CCU/IMC did not change significantly (median 1.1 vs. 1 day, 9.0% decrease; p = 0.128) (Fig. 1A and B). The rates of 30-day events were unchanged following the implementation of Benchmark (Table 4).

### Austria

Patients in Austria reported the highest rates of dizziness with exertion (65.6%), (pre-)syncope (15.9%), and CCS angina class 3/4 (11.9%), and had the highest burden of prior myocardial infarction (29.0%, p < 0.001) and pulmonary hypertension (15.4%) (Table 1). Furthermore, patients in Austria had the highest rates of atrial fibrillation (28.9%), left bundle branch block (LBBB 17.9%) and LVEF < 50% (29.0%); overall, patients treated in Austria had lower surgical risk profiles than their European counterparts (EuroSCORE II 4.0 ± 3.8) (Table 2). Almost all patients (99.0%) received LA with moderate sedation; total procedure time was comparatively short (median [IQR] 37.0 [24.0, 48.8] minutes) (Table 3). Unlike in other countries, the implementation of Benchmark did not result in the reduction of either hospital LoS (median 7 vs 7 days, p = 0.809) or critical care LoS (0.2–0.7 days, p = 0.603) (Fig. 1A and B). The rate of major vascular complications was lower after the implementation of Benchmark (0.9% vs. 6.8%), although the difference did not reach statistical significance (p = 0.056) (Table 4).

<footnote>ªMajor bleeding (BARC type 3a) defined as overt bleeding either associated with a drop in the haemoglobin level of at least 3.0 g/dL or requiring transfusion of 2 or 3 units of whole blood/RBC, or causing hospitalization or permanent injury, or requiring surgery AND does not meet criteria of life-threatening or disabling bleeding</footnote>
<figure><img src="image_3.png" /><figcaption>**Fig. 1** Hospital LoS (A) and intensive care LoS (B) prior to and post-Benchmark best practices implementation. Legend: CCU critical care unit, ICU intensive care unit, IMC intermediate care, LoS length of stay</figcaption></figure>

Discussion

The current analysis demonstrates that the implementa-
tion of Benchmark best practices resulted in reduced
LoS while maintaining patient safety in different Euro-
pean countries despite differences in healthcare systems
and patients' baseline characteristics. The adoption of an

evidence-based and expert-informed streamlined hospital
pathway for TAVI patients supported with a peer men-
torship programme can increase access to care, hospital
capacity and efficiency in treating patients with severe AS
in most European countries while optimizing outcomes.

Prior to the implementation of Benchmark, Germany
reported the longest hospital LoS compared to other
countries. The close scrutiny of processes of care and the

<figure><img src="image_4.png" /></figure>
<table><caption>**Table 4** 30-day outcomes prior and post-Benchmark implementation by country</caption><thead><tr><th>Outcome, n (%)</th><th>France (prior n=322, post n=568)</th><th>p value</th><th>Spain (prior n=206, post n=248)</th><th>p value</th><th>Germany (prior n=127, post n=235)</th><th>p value</th><th>Italy (prior n=98, post n=202)</th><th>p value</th><th>Austria (prior n=67, post n=109)</th><th>p value</th><th>p value<sup>a</sup></th></tr></thead><tbody><tr><td rowspan="2">Combined end point<sup>b</sup></td><td>Prior</td><td>3 (1.1)</td><td>0.560</td><td>5 (2.4)</td><td>0.326</td><td>2 (1.7)</td><td>1.000</td><td>2 (2.2)</td><td>0.683</td><td>2 (3.4)</td><td>0.126</td><td></td></tr><tr><td>Post</td><td>10 (1.9)</td><td></td><td>10 (4.1)</td><td></td><td>5 (2.4)</td><td></td><td>4 (4.3)</td><td></td><td>0 (0.0)</td><td></td><td>0.094</td></tr><tr><td rowspan="2">All-cause mortality</td><td>Prior</td><td>0 (0.0)</td><td>0.305</td><td>1 (0.5)</td><td>1.000</td><td>0 (0.0)</td><td>0.531</td><td>1 (1.1)</td><td>0.492</td><td>0 (0.0)</td><td></td><td></td></tr><tr><td>Post</td><td>4 (0.8)</td><td></td><td>1 (0.4)</td><td></td><td>2 (1.0)</td><td></td><td>0 (0.0)</td><td></td><td>0 (0.0)</td><td></td><td>0.913</td></tr><tr><td rowspan="2">Stroke/TIA</td><td>Prior</td><td>2 (0.8)</td><td>1.000</td><td>3 (1.5)</td><td>0.518</td><td>2 (1.7)</td><td>1.000</td><td>2 (2.2)</td><td>0.683</td><td>1 (1.7)</td><td>0.358</td><td></td></tr><tr><td>Post</td><td>5 (1.0)</td><td></td><td>6 (2.5)</td><td></td><td>3 (1.4)</td><td></td><td>4 (4.2)</td><td></td><td>0 (0.0)</td><td></td><td>0.074</td></tr><tr><td rowspan="2">Life-threatening bleeding</td><td>Prior</td><td>2 (0.8)</td><td>0.606</td><td>5 (2.4)</td><td>0.439</td><td>1 (0.9)</td><td>1.000</td><td>2 (2.2)</td><td>1.000</td><td>1 (1.7)</td><td>1.000</td><td><strong>0.002</strong></td></tr><tr><td>Post</td><td>2 (0.4)</td><td></td><td>9 (3.7)</td><td></td><td>1 (0.5)</td><td></td><td>3 (3.2)</td><td></td><td>1 (0.9)</td><td></td><td></td></tr><tr><td rowspan="2">AKI (stage 2/3, incl. dialysis)</td><td>Prior</td><td>0 (0.0)</td><td></td><td>4 (2.0)</td><td>1.000</td><td>0 (0.0)</td><td></td><td>0 (0.0)</td><td>0.497</td><td>0 (0.0)</td><td>0.538</td><td></td></tr><tr><td>Post</td><td>0 (0.0)</td><td></td><td>4 (1.7)</td><td></td><td>0 (0.0)</td><td></td><td>2 (2.2)</td><td></td><td>2 (1.9)</td><td></td><td><strong>0.002</strong></td></tr><tr><td rowspan="2">Coronary obstruction requiring intervention</td><td>Prior</td><td>1 (0.4)</td><td>0.337</td><td>1 (0.5)</td><td>1.000</td><td>3 (2.6)</td><td>0.671</td><td>0 (0.0)</td><td>1.000</td><td>0 (0.0)</td><td></td><td></td></tr><tr><td>Post</td><td>0 (0.0)</td><td></td><td>1 (0.4)</td><td></td><td>3 (1.5)</td><td></td><td>1 (1.1)</td><td></td><td>0 (0.0)</td><td></td><td>0.033</td></tr><tr><td rowspan="2">Major vascular complications</td><td>Prior</td><td>6 (2.3)</td><td>0.603</td><td>9 (4.4)</td><td>0.937</td><td>7 (5.9)</td><td><strong>&lt; 0.001</strong></td><td>6 (6.7)</td><td>0.528</td><td>4 (6.8)</td><td>0.056</td><td><strong>0.004</strong></td></tr><tr><td>Post</td><td>9 (1.7)</td><td></td><td>11 (4.5)</td><td></td><td>0 (0.0)</td><td></td><td>4 (4.3)</td><td></td><td>1 (0.9)</td><td></td><td></td></tr><tr><td rowspan="2">Re-hospitalization (all-cause)</td><td>Prior</td><td>8 (3.0)</td><td>0.746</td><td>9 (3.7)</td><td>0.650</td><td>2 (1.7)</td><td>0.716</td><td>0 (0.0)</td><td>1.000</td><td>2 (3.4)</td><td>0.618</td><td></td></tr><tr><td>Post</td><td>18 (3.5)</td><td></td><td>6 (2.9)</td><td></td><td>6 (2.9)</td><td></td><td>0 (0.0)</td><td></td><td>2 (1.9)</td><td></td><td>0.393</td></tr></tbody></table>

**Bold formatting** indicates statistical significance

AKI acute kidney injury, TIA transitory ischaemic attack, pts patients

<sup>a</sup>Cross-country comparison post-Benchmark implementation (Chi-squared or Fisher's exact test)

<sup>b</sup>Includes all-cause mortality, stroke/TIA, and valve-related re-hospitalization[27]
implementation of bundle of best practices was instrumen-
tal in achieving a 33% decrease, the highest improvement
among all reported countries. The mean hospital LoS in Ger-
many prior to Benchmark was 11.7 days, which is compara-
ble to the average TAVI hospital LoS reported in Germany
between 2020 (11.5 days) and 2022 (11.1 days) [13]. Simi-
larly, in Italy, the median hospital LoS prior to Benchmark
in our report was 7 days, which corresponds to the results of
the multicentre Italian OBSERVANT TAVI registry (median
7 days) [14]. After the implementation of Benchmark in the
participating Italian centres, the median hospital LoS was
significantly reduced by 2 days, resulting in a median of 5
days. As for the intensive care LoS, there was no reduction
documented in Italy, which may be explained by the fact
that the intensive care stay prior to Benchmark was already
low compared to the intensive care duration reported in the
OBSERVANT registry (median 1 vs. 2 days). In France, on
the other hand, the highest reduction in the intensive care
LoS was observed – from median 1.1 days prior to Bench-
mark to close to 0 days after Benchmark, meaning that the
majority of patients did not stay on an intensified care unit at
all after TAVI. The total hospital LoS was also reduced from
median 5 to 3 days. The recent analysis of the FRANCE 2
and FRANCE-TAVI registries as well as the single-payer
national health data system (SNDS) reported a median LoS
of 5 days in the period between 2010 and 2021, which cor-
responds to the number observed in our registry prior to the
implementation of Benchmark best practices [15]. In Spain,
a significant decrease in the total hospital LoS (median 6 to
4 days) and intensive care LoS (median 1.7 to 1 day) was
observed as well. The median hospital LoS reported in the
Spanish TAVI registry was 6 days, which, once again, cor-
responds with the duration of hospital admission recorded
in our registry prior to the introduction of Benchmark best
practices [16]. Thus, patients in this registry documented
prior to the implementation of Benchmark had a hospital
LoS similar to multiple other registries, which accurately
reflects real world practice and indicates the effectiveness of
Benchmark best practices in reducing hospital LoS in these
patient populations.

The reduction in the total hospital LoS was observed
in all considered countries, except for Austria, where nei-
ther the length of hospital stay nor intensive care stay were
reduced. Notably, Austrian patients tended to have a sicker
profile at baseline compared to other countries. These
patients tended to be more symptomatic and having prior
myocardial infarction, pulmonary hypertension, atrial fibril-
lation, LBBB, and LVEF<50% more often. Interestingly,
this finding is not reflected in the EuroSCORE II, which
appeared to be on lower side of the spectrum (4.0±3.8).
However, the characteristics of the current Austrian popu-
lation are different when comparing these patients to those
included in the nationwide Austrian TAVI registry as well

as the recent AUTHEARTVISIT study [17, 18]. The reason
for this inconsistency may be the fact that the Austrian TAVI
registry included patient data from 11 centres for interven-
tional cardiology representing 100% of Austrian institutions
offering TAVI by vascular access sites, whereas the AUT-
HEARTVISIT study included patient data from the Austrian
Insurance funds from 2010 through 2020, making the profile
of the Austrian patient population reported in the current
analysis less representative.

Besides the decrease in hospital LoS, one major goal of
the Benchmark implementation was to preserve safety after
TAVI. In our report, the 30-day safety was uncompromised
in all countries included, which reinforces the results pub-
lished for the total BENCHMARK population [10]. Moreo-
ver, there was no increase in the rate of hospital readmission
documented after the implementation of Benchmark best
practices, despite earlier discharge. There was also a signifi-
cant reduction in the rates of major vascular complications
in Germany after the implementation of Benchmark best
practices (5.9% vs. 0.0%). The rates of all-cause mortality
were quite low across all countries (< 1.0%) before and also
with the implementation of Benchmark best practices com-
pared to the previously reported rates in other registries.
For instance, the 30-day mortality in the combined analysis
of French TAVI registries was 4.0% compared to 0.0% and
0.8% prior to and after Benchmark implementation, respec-
tively [15]. Similarly, the Italian OBSERVANT registry
reported the rates of 30-day mortality to be 6.7% in males
and 5.1% in females as opposed to 1.1% prior to and 0.0%
after Benchmark in our registry [14]. Same differences are
observed when comparing the 30-day mortality rates from
the Spanish, German, and Austrian TAVI registries with
the rates presented here [16, 18, 19]. Lower mortality rates
in our patient population may be partially attributed to the
lower risk profile of TAVI patients, better device technology
with the use of new generation valves as well as increased
operator experience.

Streamlining care by shortening hospital LoS offers a
number of benefits, including minimizing hospital costs and
resources related to unnecessary hospitalization time and the
positive outcomes of early mobilization. Furthermore, the
risk of in hospital-acquired infections and hospital readmis-
sion at 30 days is also reduced when patients are discharged
earlier after TAVI [20, 21]. Based on our findings and other
reports, the main drivers of accelerated recovery and short-
ened hospital LoS include various preventive measures,
such as determination of an anticipated discharge based on
pre-procedural risk stratification, the use of cardiac cath-
eterization laboratory and local anaesthesia with or without
light procedural sedation, removal of the temporary pace-
maker at the end of the procedure, post-procedure echo- or
angiographic check to confirm proper closing of access site,
and the reduced use of critical care facilities [9, 22, 23]. In
addition, patient and family engagement to facilitate shared
decision-making plays a crucial role in early discharge. It
is important to note, however, that several factors, such as
cultural norms and the challenges of change management,
should be considered for the wider adoption of Benchmark
best practices across various countries. For example, local
reimbursement issues related to the fixed minimum hospital
stay duration, lack of resources, or certain attitudes and ide-
ologies may result in stronger resistance to change. However,
the use of contemporary evidence, peer-to-peer coaching
and strong focus on quality improvement and access to care
demonstrated in the BENCHMARK registry may serve as
facilitators to the broader implementation of a streamlined
patient pathway.

From the economical perspective, TAVI itself has become
a superior approach in terms of lower costs and better out-
comes compared with surgery and the shorted hospital LoS
adds an additional economic benefit to that. In the propen-
sity-matched economic analysis of the 3M-TAVR registry,
the minimalist clinical pathway led to ≈$11,000 lower
cumulative costs at 30 days, of which > $8000 were saved
in non-procedure related costs during the index hospitaliza-
tion, driven primarily by shorter LoS [24]. A shorter hospital
stay also allows additional hospital revenue by freeing up
hospital beds for other patients [24]. While LoS is the major
contributor to TAVI costs, the avoidance of general anaes-
thesia, resulting in shorter procedure times, and minimal
use of critical care services result in further savings [25,
26]. The planned economic analysis of the BENCHMARK
registry will further assess potential costs savings associated
with the implementation of best practices across different
healthcare systems.

Limitations

Although the present analysis successfully demonstrated
the effectiveness of implementing Benchmark best prac-
tices across different European countries, it comes with
limitations: This international, multicentre registry is purely
observational, with the inherent limitations and potential
bias on data collection, such as a higher potential for miss-
ing data. However, the observational design carries several
advantages, including the assessment of TAVI patients in
a real-world setting (high external validity), avoiding the
existing issue of the strict inclusion and exclusion criteria
used for randomized research (high internal, but less external
validity). In addition, while the international nature of this
study is highly advantageous and increases the applicabil-
ity of our findings to other European countries, differences
in the healthcare systems in each country (e.g., financial
aspects, standard procedural and post-TAVI protocols, etc.)
need to be considered when interpreting the findings. This

was the reason for the present analysis. Lastly, the clinical
outcomes were not independently adjudicated, which may
have introduced a certain level of bias.

Conclusion

The findings from the present analysis highlight that the
implementation of Benchmark best practices in different
European healthcare systems is equally effective in stream-
lining TAVI patient pathways by reducing hospital LoS
without compromising on patient safety. Thus, the benefits
of Benchmark best practices seem to extend beyond national
borders, country peculiarities and patient profiles, primar-
ily improving patients’ TAVI pathway. However, the break-
down of TAVI-specific parameters by country before and
after implementation of Benchmark best practices enables to
broaden its scope to more countries and centres. As a results,
country specific measures are currently being developed to
enable a further optimization and refinement of the TAVI
pathway.

**Supplementary Information** The online version contains supplementary material available at https://doi.org/10.1007/s00392-025-02638-z.

**Acknowledgements** We thank Marie Zielinski, Daniel Greinert, Cornelia Deutsch, and Nataliya Trushina from IPPMed, Cloppenburg, for sponsor representation, excellent project management, and support with statistics. Lastly, we thank all the nursing and study coordinators from each participating centre for their immense support and active contribution to facilitating this study: Carlos Lara García, Beatriz Chamorro (Malaga, Spain); Jean-Philippe Claudel, Hervé Perrier, Viktoria Frebault (Lyon, France); Catalina Andreea Parasca (Bucharest, Romania); Katia Lassouani (Tours, France); Wassim Zitouni, Sonia Soltani (Montpellier, France); Rosalie Le Gal (Rennes, France); Elena Jimenez Xarrie (Barcelona, Spain); Niccolo Ciardetti, Francesco Meucci (Florence, Italy); Imane Bagdadi (Paris, France); Petr Raška (Prague, Czech Republic); Georg Delle-Karth, Claudia Schuster, Marie-Christine Leitgeb (Vienna, Austria); Esther Bernardo García, María Aránzazu Ortega Pozzi (Madrid, Spain); Jürgen Leick, Michael Lauterbach, Hannah Waschbüsch (Trier, Germany); Guillem Muntané (Barcelona, Spain); Olga Daxböck, Mirela Butkovic, Simona Popescu (St. Pölten, Austria); Martina Perrero (Turin, Italy); Stephanie Watbled (Besancon, France); Maxence Delomez (Lille, France); Bruno Scheller, Sebastian Ewen, Ann-Kathrin Berger, Christina Koch, Alexandra Engel (Homburg, Germany); Paolo Olivares (Milan, Italy); Frieder Wolf, Carolin Müller, Maren Hünermund (Göttingen, Germany); Mathias Konstandin, Lisa Linz, Hannah Ulbricht (Heidelberg, Germany); Sabrina Siame (Marseille, France); Nassima Ait Amrane (Pitie Salpetriere, Paris, France); Dow Rosenzweig (Munich, Germany); Barbara Cefalo (Avellino, Italy); Vera Wolf (Cologne, Germany); Jaume Maristany Daunert, Maria Carmen de la Bandera Sanchez (Mallorca, Spain).

**Author contributions** Conception and design: Francesco Saia, Sandra Lauck, Eric Durand, Douglas Muir, Mark Spence, Mariuca Vasa-Nicotera, David Wood, Gemma McCalmont, Radka Rakova, Wilbert Wesselink, Jana Kurucova, Claudia M. Lüske, Peter Bramlage, Derk Frank. Acquisition, analysis, or interpretation of data for the work: Cristóbal A. Urbano-Carrillo, Damien Bouchayer, Vlad Anton Iliescu, Christophe Saint Etienne, Florence Leclercq, Vincent Auffret, Lluis Asmarats, Carlo Di Mario, Aurelie Veugeois, Jiri Maly,
Andreas Schober, Luis Nombela-Franco, Nikos Werner, Joan Antoni Gómez-Hospital, Julia Mascherbauer, Guiseppe Musumeci, Nicolas Meneveau, Thibaud Meurice, Felix Mahfoud, Federico De Marco, Tim Seidler, Florian Leuschner, Patrick Joly, Jean Philippe Collet, Ferdinand Vogt, Emilio Di Lorenzo, Elmar Kuhn, Vincent Peral Disdier, Violetta Hachaturyan. Writing the first draft: Francesco Saia, Sandra Lauck, Eric Durand, Douglas Muir, Mark Spence, Mariuca Vasa-Nicotera, David Wood, Gemma McCalmont, Violetta Hachaturyan, Peter Bramlage, Derk Frank. Revising the article for important intellectual content: Cristóbal A. Urbano-Carrillo, Damien Bouchayer, Vlad Anton Iliescu, Christophe Saint Etienne, Florence Leclercq, Vincent Auffret, Lluis Asmarats, Carlo Di Mario, Aurelie Veugeois, Jiri Maly, Andreas Schober, Luis Nombela-Franco, Nikos Werner, Joan Antoni Gómez-Hospital, Julia Mascherbauer, Giuseppe Musumeci, Nicolas Meneveau, Thibaud Meurice, Felix Mahfoud, Federico De Marco, Tim Seidler, Florian Leuschner, Patrick Joly, Jean Philippe Collet, Ferdinand Vogt, Emilio Di Lorenzo, Elmar Kuhn, Vicente Peral Disdier, Radka Rakova, Wilbert Wesselink, Jana Kurucova, Violetta Hachaturyan, Claudia M. Lüske. Approving the article for submission: Francesco Saia, Sandra Lauck, Eric Durand, Douglas Muir, Mark Spence, Mariuca Vasa-Nicotera, David Wood, Cristóbal A. Urbano-Carrillo, Damien Bouchayer, Vlad Anton Iliescu, Christophe Saint Etienne, Florence Leclercq, Vincent Auffret, Lluis Asmarats, Carlo Di Mario, Aurelie Veugeois, Jiri Maly, Andreas Schober, Luis Nombela-Franco, Nikos Werner, Joan Antoni Gómez-Hospital, Julia Mascherbauer, Giuseppe Musumeci, Nicolas Meneveau, Thibaud Meurice, Felix Mahfoud, Federico De Marco, Tim Seidler, Florian Leuschner, Patrick Joly, Jean Philippe Collet, Ferdinand Vogt, Emilio Di Lorenzo, Elmar Kuhn, Vicente Peral Disdier, Gemma McCalmont, Radka Rakova, Wilbert Wesselink, Jana Kurucova, Violetta Hachaturyan, Claudia M. Lüske, Peter Bramlage, Derk Frank.

**Funding** Open Access funding enabled and organized by Projekt DEAL. The study was funded by Edwards Lifesciences and performed under the sponsorship of IPPMed—Institute for Pharmacology and Preventive Medicine GmbH, Cloppenburg, Germany.

**Data availability** Available from the corresponding author upon reasonable request.

## Declarations

**Conflict of interest** FS received payment for lectures/presentations from Edwards Lifesciences, Medtronic, and Abbott and is on the Data Safety Monitoring Board/Advisory Board of Edwards Lifesciences. SL received consulting fees and support for attending meetings from Edwards Lifesciences and Medtronic. ED received consulting fees from Edwards Lifesciences. DFM received support for the present manuscript, consulting fees, payment for lectures/presentations, and support for attending meetings from Edwards Lifesciences. DF received consulting fees from Edwards Lifesciences. CAUC received consulting fees from Edwards Lifesciences, payment for lectures/presentations from Medtronic and Biotronik, and is on the Data Safety Monitoring Board/Advisory Board of Medtronik. CSE received consulting fees from Medtronic, Edwards Lifesciences, and Abbott. VA received consulting fees from Boston Scientific and payment for lectures/presentations from Edwards Lifesciences, Medtronic, and Abbott. LA received speaker feeds from Edwards Lifesciences. JM received grants, consulting fees, and payment/honoraria for lectures/presentations from Edwards Lifesciences, payment for lectures/presentations from St. Jude Medical Coordination Center BVBA (Abbott), and stock on Leviticus Cardio Ltd. AS received grant from Edwards Lifesciences. LNF received consulting fees from Edwards Lifesciences and Abbott Vascular. NW received grant from Shockwave Medical and Abiomed, support for attending meetings from Edwards Lifesciences, Medtronic,

and Boston, and is on the Data Safety Monitoring Board/Advisory Board of the Cingular Study. JM (Julia Mascherbauer) received grants and support for attending meetings from Boston Scientific, Medtronic, Edwards Lifesciences, grant from Abbott, payment for lectures/presentations from Edwards Lifesciences and AOP, is on Data Safety Monitoring Board/Advisory Board of Amgen, and is ESC Nominating Committee Member 2022–2024. GMC received honoraria for consultancy for the present manuscript, educational grant, consulting fees, and payment for lectures/presentations from Edwards Lifesciences and is now an employee of Edwards Lifesciences. JK, WW, and RR are employees of Edwards Lifesciences. PB is representing the sponsor IPPMed who received funding from Edwards Lifesciences for performing the study. VH and CL are employees of IPPMed. DF received support for the present manuscript, payment for lectures/presentations, and support for attending meetings from Edwards Lifesciences. All other authors represent centres who received compensation from Edwards Lifesciences for the documentation of patients.

**Ethical approval and informed consent** The registry was approved by the independent ethics review boards at each participating site and all patients provided written informed consent.

**Open Access** This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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## Authors and Affiliations

Francesco Saia¹ · Sandra Lauck² · Eric Durand³ · Douglas F. Muir⁴ · Mark Spence⁵ · Mariuca Vasa-Nicotera⁶ ·

David Wood² · Cristóbal A. Urbano-Carrillo⁷ · Damien Bouchayer⁸ · Vlad Anton Iliescu⁹ · Christophe Saint Etienne¹⁰ ·

Florence Leclercq¹¹ · Vincent Auffret¹² · Lluis Asmarats¹³ · Carlo Di Mario¹⁴ · Aurelie Veugeois¹⁵ ·

Jiri Maly¹⁶ · Andreas Schober¹⁷ · Luis Nombela-Franco¹⁸ · Nikos Werner¹⁹ · Joan Antoni Gómez-Hospital²⁰ ·

Julia Mascherbauer²¹ · Giuseppe Musumeci²² · Nicolas Meneveau²³ · Thibaud Meurice²⁴ · Felix Mahfoud²⁵ ·

Federico De Marco²⁶ · Tim Seidler²⁷,²⁸ · Florian Leuschner²⁹ · Patrick Joly³⁰ · Jean Philippe Collet³¹ ·

Ferdinand Vogt³²,³³ · Emilio Di Lorenzo³⁴ · Elmar Kuhn³⁵ · Vicente Peral Disdier³⁶,³⁷ · Gemma McCalmont³⁸ ·

Radka Rakova³⁸ · Wilbert Wesselink³⁸ · Jana Kurucova³⁸ · Violetta Hachaturyan³⁹ · Claudia M. Lüske³⁹ ·

Peter Bramlage³⁹ • Derk Frank⁴⁰,⁴¹ • for the BENCHMARK Investigator Group

<figure><img src="image_5.png" /></figure>

Derk Frank

derk.frank@uksh.de

Francesco Saia

francesco.saia@unibo.it

Sandra Lauck

slauck@providencehealth.bc.ca

Eric Durand

eric.durand@chu-rouen.fr

Douglas F. Muir

douglasmuir@nhs.net

Mark Spence

markspence1@yahoo.co.uk
Mariuca Vasa-Nicotera
m.nicotera@klinikverbund-suedwest.de

David Wood
david.wood@vch.ca

Cristóbal A. Urbano-Carrillo
cristobalurbano@gmail.com

Damien Bouchayer
dr.bouchayer@infirmerie-protestante.com

Vlad Anton Iliescu
vladanton.iliescu@gmail.com

Christophe Saint Etienne
c.saintetienne@chu-tours.fr

Florence Leclercq
f-leclercq@chu-montpellier.fr

Vincent Auffret
vincent.auffret@chu-rennes.fr

Lluis Asmarats
lasmarats@santpau.cat

Carlo Di Mario
carlo.dimario@unifit.it

Aurelie Veugeois
aurelie.veugeois@imm.fr

Jiri Maly
jiri.maly@ikem.cz

Andreas Schober
andreas.schober@gesundheitsverbund.at

Luis Nombela-Franco
luisnombela@yahoo.com

Nikos Werner
n.werner@bbtgruppe.de

Joan Antoni Gómez-Hospital
jagomezh@bellvitgehospital.cat

Julia Mascherbauer
julia.mascherbauer@stpoelten.lknoe.at

Giuseppe Musumeci
giuseppe.musumeci@gmail.com

Nicolas Meneveau
nicolas.meneveau@univ-fcomte.fr

Thibaud Meurice
tmeurice@icloud.com

Felix Mahfoud
felix.mahfoud@uks.eu

Federico De Marco
federico.demarco@gmail.com

Tim Seidler
tim.seidler@med.uni-goettingen.de

Florian Leuschner
florian.leuschner@med.uni-heidelberg.de

Patrick Joly
pjoly@cardiovista.fr

Jean Philippe Collet
jean-philippe.collet@aphp.fr

Ferdinand Vogt
ferdinand.vogt@artemed.de

Emilio Di Lorenzo
emidilorenzomd@gmail.com

Elmar Kuhn
elmar.kuhn@uk-koeln.de

Vicente Peral Disdier
vicente.peral@ssib.es

Gemma McCalmont
gemma_mccalmont@edwards.com

Radka Rakova
radka_rakova@edwards.com

Wilbert Wesselink
wilbert_wesselink@edwards.com

Jana Kurucova
jana_kurucova@edwards.com

Violetta Hachaturyan
violetta.hachaturyan@ippmed.de

Claudia M. Lüske
claudia.lueske@ippmed.de

Peter Bramlage
peter.bramlage@ippmed.de

<figure><img src="image_6.png" /></figure>

<footnote n="1">1 Department of Cardiology, Policlinico S. Orsola-Malpighi,
University of Bologna, Bologna, Italy</footnote>

<footnote n="2">2 Centre for Cardiovascular Innovation, University of British
Columbia, Vancouver, BC, Canada</footnote>

<footnote n="3">3 Department of Cardiology, University Hospital of Rouen,
Rouen, France</footnote>

<footnote n="4">4 Cardiology Department, James Cook University Hospital,
Middlesbrough, UK</footnote>

<footnote n="5">5 Cardiology Department, Mater Private Network, Dublin,
Ireland</footnote>

<footnote n="6">6 Cardiology Department, Hospital Sindelfingen-Böblingen,
Sindelfingen, Germany</footnote>

<footnote n="7">7 Cardiology Department, Hospital Regional Universitario de
Málaga, Malaga, Spain</footnote>

<footnote n="8">8 Department of Cardiology, The Clinique de L'Infirmerie
Protestante, Lyon, France</footnote>

<footnote n="9">9 Department of Cardiovascular Surgery, University
of Medicine and Pharmacy Carol Davila, Bucharest, Romania</footnote>

<footnote n="10">10 Department of Cardiology, Centre Hospitalier Regional
Universitaire de Tours, Hôpital Trousseau, Tours, France</footnote>

<footnote n="11">11 Cardiology Department, Montpellier University Hospital,
Montpellier University, Montpellier, France</footnote>

<footnote n="12">12 CHU Rennes Service de Cardiologie, Inserm LTSI U1099,
Université de Rennes 1, Rennes, France</footnote>

<footnote n="13">13 Cardiology Department, Hospital de la Santa Creu I Sant Pau,
Instituto de Investigación Biomédica Sant Pau, Barcelona,
Spain</footnote>

<footnote n="14">14 Structural Interventional Cardiology Division, Department
of Clinical & Experimental Medicine, Careggi University
Hospital, Florence, Italy</footnote>
15 Department of Cardiology, Institut Mutualiste Montsouris, Paris, France

16 Cardiac Center, IKEM Prague, Prague, Czech Republic

17 Department of Cardiology, Hospital Floridsdorf and the Karl Landsteiner Institute for Cardiovascular and Critical Care Research Vienna, 1210 Vienna, Austria

18 Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain

19 Medical Department III, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany

20 Heart Diseases Institute, Bellvitge University Hospital - IDIBELL, L'Hospitalet de Llobregat, University of Barcelona, Barcelona, Spain

21 Department of Internal Medicine 3/Cardiology, University Hospital St. Pölten, St. Pölten, Austria

22 Cardiology Division, AO Ordine Mauriziano, Turin, Italy

23 Cardiology, Besancon Regional University Hospital Center, Besancon, France

24 Cardiology, Polyclinique Du Bois, Lille, France

25 Internal Medicine III, Cardiology, Angiology and Internal Intensive Care Medicine, University Hospital of Saarland, Homburg, Germany

26 Centro Cardiologico Monzino IRCCS, Milan, Italy

27 Department of Cardiology and Pulmonology, Georg-August-University, Göttingen, Germany

28 Department of Cardiology, Campus Kerckhoff of the Justus-Liebig-Universität Gießen, Kerckhoff-Clinic, German Centre for Cardiovascular Research (DZHK), Bad Nauheim, Germany

29 Department of Medicine III, German Centre for Cardiovascular Research (DZHK), University of Heidelberg, Heidelberg, Germany

30 Department of Interventional Cardiology, Hôpital Saint Joseph, Marseille, France

31 Department de Cardiologie, Hôpital de Pitié-Salpêtrière AP-HP, Paris, France

32 Department for Cardiovascular Surgery, Artemed Klinikum München, Munich, Germany

33 Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany

34 U.O.C. Cardiologia/UTIC "d. Rotiroti", Department of Cardiology and Cardiovascular Surgery, A.O.R.N. San Giuseppe Moscati Avellino, Avellino, Italy

35 Faculty of Medicine, Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany

36 Cardiology Department, Hospital Universitari Son Espases, Palma, Spain

37 Grupo de Investigación de Fisiopatología y Terapéutica Cardiovascular, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain

38 Edwards Lifesciences, Prague, Czech Republic

39 Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany

40 Department of Internal Medicine III (Cardiology and Critical Care Medicine), University Clinical Centre Schleswig-Holstein (UKSH), Kiel, Germany

41 German Centre for Cardiovascular Research, Partner site Hamburg/Kiel/Lübeck, Arnold-Heller Strasse 3, 24105 Kiel, Germany