Transcatheter aortic valve replacement (TAVR) continues to be one of healthcare’s great success stories, quickly surpassing surgical aortic valve replacement as the go-to treatment option for a large number of patients who present with symptomatic severe aortic stenosis. But what is next for this rapidly evolving procedure? What trends should we keep an eye on as time goes on?
To find out, Cardiovascular Business spoke with interventional cardiologist Samir Kapadia, MD, chair of the department of cardiovascular medicine at Cleveland Clinic. Read the conversation below:
When you think about the state of TAVR in 2023, what comes to mind? What TAVR-related trends should hospitals and health systems be focused on in the years ahead?
Samir Kapadia: When it comes to TAVR, progress has been moving at an exponential rate. The first TAVR valve was implanted in 2002, and it became the standard of care in just 20 years.
And when you think about it, from the first valve that was replaced in United States to any valve that gets replaced today, every valve is monitored. Every TAVR patient is included in the Society of Thoracic Surgeons/American College of Cardiology TVT Registry, and the data are stored and available for analysis for every patient. This is a very unique situation—no other technology or treatment has this kind of data or has gone on this kind of scientific journey.
One big change in TAVR is that more devices are available now than there were in the past, and even more devices are being investigated. And what has happened is, instead of focusing on the patient—their age, their comorbidities, their clinical situation—we are now more focused on the anatomy. The anatomy is the main feature, the main reason that we decide whether we are going to go with TAVR or surgery. The main deciding factor is no longer the patient’s comorbidities or if they are a high-risk or low-risk patient. Instead, now we are talking about the anatomy. Is the anatomy such that TAVR is going to be a lifetime solution to the patient’s aortic stenosis?
In the coming years, we are going to look more at the lifetime management of a patient’s aortic stenosis. If a patient is 60 years old and needs an aortic valve replacement, what is the best way to replace the valve and ensure that we aren’t regretting that decision in the future? The last valve replacement a patient gets, when they are 80 or 90 years old, should be done using TAVR. We will need to have a strategy that helps us achieve that goal and lets the patient live a long, healthy life without aortic stenosis.
In this video, Samir Kapadia, MD, chairman of the Department of Cardiovascular Medicine, Cleveland Clinic, explains what cardiology departments and TAVR programs need to do to become top-ranked centers. Cleveland Clinic is consistently ranked one of the top cardiovascular centers in the country by U.S. News and World Report each year.
TAVR is now being considered for younger patients than it was in the past. Do you think the indications for TAVR will continue to evolve?
Samir Kapadia: Like I said, lifetime management is going to be a bigger focus in the future. Indications are a big part of that. Are we going to be able to treat patients earlier? Are we going to be able to treat more patients with aortic stenosis? What about patients with aortic regurgitation or those who have already undergone TAVR? Those are the kinds of questions you are going to see more of in the coming years.
The second part of that discussion is, can we keep making these procedures safer and safer? Can we prevent strokes from happening? Are we able to prevent trauma related to valve deployment? These safety features are all of prime importance. We want to increase the population of patients who can undergo TAVR—and we want to remain safe as we do that. And we are already talking about low mortality, a low stroke risk and a low risk of major complications, so to see the difference between these different valves and different ways of doing things, it is going to require data from hundreds of thousands of patients.
This is an important transition in the TAVR world—we are saying we want to fine-tune these procedures, but we have to retain the academic excellence and ensure we are not misguided. This is a challenge because there are a lot of financial incentives related to TAVR—that is the reason it has grown so quickly, because it is a profitable business and one that can generate funding. This is a positive thing, not a negative. The industry is behind TAVR and wants to make it better.
As doctors and investigators, of course, we are rigorous about trying to understand what the right thing to do or wrong thing to do is for our patients. Did we gather enough data to judge an alternative strategy or a new therapy? These types of questions are where the industry is headed right now.
Samir Kapadia, MD, chairman of the Department of Cardiovascular Medicine, Cleveland Clinic, explains in this short video that the durability of TAVR valves remains one of the key unanswered questions.
What is an unanswered question that you still have about TAVR?
Samir Kapadia: The most important unanswered question is the durability. We are getting more and more answers about durability in the sense that we do so many TAVR valves, and we are not seeing those patients come back. I got Christmas cards this year from several of them saying that they’re so thankful and that the valve is working just fine … it gives you a lot of confidence in these valves. The unanswered question is, when you are going to put a new valve inside of another valve, what will be the durability? Is it going to be similar [to the prior valve] or less? A lot of different companies are now designing devices to improve durability, but how do we test that? Is there a way to test those devices with some kind of surrogates? These are important questions.
Cleveland Clinic is regularly cited as one of the top hospitals in the United States for cardiology and heart surgery, and its TAVR program has been a huge part of that success. Can you share any words of wisdom for other TAVR programs?
Samir Kapadia: The most important part is that this is a team sport; it is not about individuals. For the nurses, the doctors, the surgeons, cardiologists, imaging doctors, all of us, there is one simple goal. That goal is not to do good business. That goal is not to be famous. That goal is not to do something that other people could not do. The goal is to take the best care of the patient. Treat every patient how you would treat a family member. If everybody who walks in—rich, poor, old, young—is treated with that one goal in mind and we treat them the best possible way, as a team, than everything else falls into place. Everything else is secondary.
There are so many people in the world that want the best care. If you are able to provide the best care, well, you definitely don’t need any advertisements, nothing like that. Everything else will work. That is the most important message—don’t worry about, you know, competing with people or any of those things. If everybody is focused on the patient, everything will be good.
This conversation was edited for space.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.