TCT.14: Successful valve practices embrace change

WASHINGTON, D.C.—If surgeons want to remain relevant in cardiology, they had better be open to change, warned the co-director of a high-volume transcatheter aortic valve replacement (TAVR) center at the Transcatheter Cardiovascular Therapeutics scientific session.

“In 2014, the cardiac surgeon has to be flexible in the therapies available for aortic surgery,” said Vinod Thourani, MD, chief of cardiothoracic surgery at Emory Hospital Midtown and co-director of the Surgical Heart and Valve Center at Emory University in Atlanta. He spoke Sept. 13 at a session on aortic valve therapies. “If you are not, you will become obsolete. In two or three years, you will not have an aortic valve practice.”

In 2007, Thourani offered patients with aortic valve disease three options, all standard care. As an investigator in the PARTNER TAVR trial, he could add six minimally invasive offerings after the study launched. The Emory team has since performed hundreds of TAVR procedures.

Today’s practicing cardiothoracic surgeons are adept at open surgery techniques performed in traditional operating rooms but their areas of comfort and expertise may not mesh with patient preferences. Patients want the least invasive procedure, shorter stays, faster recoveries and the best outcomes, he said.

To accommodate them, surgeons will need to change their way of thinking. Thourani supported the use of the heart team approach championed with TAVR, which promotes the exchange of viewpoints to settle on a plan of care for patients with severe aortic stenosis. He also advocated the use of a hybrid cardiac interventionalist who can perform procedures in the cath lab, with the caveat that the surgeons are trained and qualified beforehand.

“We need to institute catheter skills immediately,” he proposed. “We need to enhance the understanding of the cardiology practice to our trainees and we need more formal fellowships.”

Emory employs a minimalist approach that allows for transfemoral TAVRs to be conducted in a cath lab with local anesthesia, which translates into a shorter length of stay for patients and lower costs for the hospital. As done at Emory and some other institutions, the program supports the development and use of a dedicated valve specialist, a position that includes both cardiologists and cardiac surgeons.

The success of TAVR hinges not only on the skills of practicing heart teams and hybrid professionals but also on their ability to train the next generation, he said. As technologies, skills and personnel evolve, successful practices will not be restricted to one valve or procedure.

“It is not just aortic valves,” Thourani predicted. “It is about mitral valves next and tricuspid valves after that and then pulmonics.”