TAVR in Standard Risk Patients: A Runaway Freight Train?

2.1 / IAGS 2019
Session 2: Structural Session 1 - Aortic
TAVR in Standard Risk Patients: A Runaway Freight Train?
Problem Presenter: Gus Pichard, MD

Statement of the problem or issue

Today there are 602 TAVR approved Centers in the United States. As I travel among centers I have observed that not all patients are getting optimal care. I have seen cases with (a) inadequate indication, (b) inadequate device selection, (c) inadequate procedural steps, and (d) inadequate treatment post procedure. This is probably related to lack of current information, lack of expertise, economic incentives, regional competitive forces, and hospital policies leading to inappropriate decisions in some patients. I have seen it in high volume and low volume TAVR Centers. At the IAGS Meeting I showed several case examples to illustrate each one of these points.

Gaps in knowledge

TAVR is a new procedure that has rapidly expanded in the last decade. A great effort by the leaders in this field has generated strong data, based on randomized clinical trials and carefully conducted registries, leading to approval of the procedure with certain very specific guidelines.

Many gaps in knowledge remain. The next 1-2 decades will bring important information that will modify importantly the TAVR world: who does TAVR, which device is optimal for each patient, which patient gets TAVR and when, which ancillary procedures should be considered, how is the TAVR patient cared for during and after the procedure, etc.

Possible solutions and future directions

New data are continuously being generated in scientific publications, leading to important changes in patient selection, procedural aspects, and post procedural management. The TAVR experts are continuously meeting to try and interpret existing data, to share experiences, to discuss possible best strategies, and to suggest practical recommendations. Implanters need to remain involved in these activities to keep up with progress.

The TVT Registry compiles all cases performed in the US (a requirement for reimbursement) and provides important clinical, procedural and outcomes information with follow-up to one year. The TVT Registry has the ability to pinpoint “outliers” and calls the institution asking for corrections.

CMS has recently proposed a liberalization of requirements to begin a TAVR program in an attempt to facilitate access to care. As long as the Heart Teams remain strong, very well informed, and monitored by national organizations, patients may benefit. The need for “expertise” on the interventional team remains very strong; this is not a procedure to perform occasionally.

A successful TAVR program also needs to invest in an effective and comprehensive effort for the education of the patient and family before and after the TAVR procedure, to fulfill the main objective of TAVR: enhance the patient’s well-being and long-term outcome.