A Heart Team Perspective Interventional cardiology Megan Coylewright MD MPH FSCAI DartmouthHitchcock Heart and Vascular Center Cardiac surgery Melissa Levack MD Vanderbilt University Medical Center ID: 1035916
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1. Do We Have Enough TAVR Centers?A Heart Team PerspectiveInterventional cardiology: Megan Coylewright, MD MPH FSCAIDartmouth-Hitchcock Heart and Vascular CenterCardiac surgery: Melissa Levack, MDVanderbilt University Medical Center
2. DisclosuresDr. Coylewright: Boston Scientific: research and honoraria Edwards LifeSciences: research and honoraria W.L. Gore: honorariaDr. Levack: Boston Scientific: honoraria Edwards LifeSciences: honoraria
3. AgendaSystems of CareTwo case studies of severe AS
4. TAVR National Coverage Determination, 2020
5. Nishimura et al. JACC 2019
6. Nishimura et al. JACC 2019
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8. “…the humility of knowing one’s limitations is an important element of competence.”Harvey Max Chochinov, CMAJ 2010“Absolute certainty leaves little room for shared decision-making.”
9. Case 159 year old maleBicuspid AV with severe AS5.3 cm ascending aortic aneurysm
10. BAV Aneurysm
11. Valve Selection ChoiceN Engl J Med 2017; 377: 1847-1857Long term mortality benefit for mechanical prosthesis compared to biologic prosthetic persists until age 55 in patients undergoing aortic valve replacement
12. Aortic Aneurysm Guidelines 2014 AHA guidelinesClass IIa: Elective intervention for aortic aneurysm is reasonable in asymptomatic patients with BAV if root or ascending is 5.0 cm or greater AND there is an additional risk factor for dissection (family history of aortic dissection or growth rate 0.5 cm or greater per year (or if low risk and surgery performed at an expert center with experience) or when ratio of maximal ascending or aortic root area divided by patients height exceeds 10 (Index)Class IIa: Elective intervention for aortic aneurysm is reasonable in asymptomatic patients with BAV undergoing AVR when diameter of aorta is 4.5 cmIn selected patients with aortic dilatation and family history of thoracic aortic disease, genetic consultation and testing may be useful in determining the timing of intervention2014/2017 AHA guidelinesClass I: Operative intervention is indicated in asymptomatic patients with BAV if the diameter of the root or ascending is 5.5 cm or greater center with experience) or when ratio of maximal ascending or aortic root area divided by patients height exceeds 10 (Index)
13. Aortopathy and BAVAssociated AortopathyAortic dilatation present in 20-42% of patients with BAVActive ongoing surveillance critical for BAV (and TAV) aneurysmsRisk of dissection and rupture are catastrophic Surveillance requires increased doctor visits, aggressive BP management, yearly imaging and increases healthcare costs Svensson et al. (2011) – Valve alone vs Valve-AortaNO increase risk of death, stroke, or other serious complication related to surgery
14. Shared Decision Making Is it better to do SAVR + ascending aortic replacement at the time of index operation vs TAVR and active surveillance of aneurysm at index?This discussion will evolve with younger and lower risk patientsIf TAVR alone selected, what TAVR valve option is best suited?
15. Case 268 year old woman with hypertensionSevere tricuspid aortic stenosisStrong value to remain close to home, especially in COVID era
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17. 540Hospitals performing TAVR1,103Hospitals performing Surgical AVRHospitals where SAVR is the only therapeutic treatment option for severe symptomatic AS563Data Source: FY2017 MEDPAR, presented by Dr. Leon at MEDCAC meeting, July 25, 2018
18. What influences our choice of therapy?What is most important to patients?SAVRLonger term data on durabilityLess PVRCABG, MAZE, LAAOLower pacemaker Locally availableClinician preferenceTAVRReduced risk AF, bleeding, renal failureLess strokeRapid return to work/activities/QOLLess burden on othersMore “days at home”Adapted in part from MEDCAC presentation, Dr. Leon for AdvaMed, July 25, 2018; Still et al. Current Cardiology Reports 2018Disabling stroke/mortality
19. Life expectancy after aortic valve replacementGlaser et al. JACC 2019At 10 years, 71% of patients 65-75 years are still alive
20. Mcclure et al. Ann Thorac Surg 2010At 15 years, 18% of patients65-75 years are still alive
21. “…the incorporation of patient preferences and values into patients’ treatment decisions.”
22. https://app.magicapp.org/app#/guideline/1308
23. Do We Have Enough TAVR Centers?A Heart Team PerspectiveMelissa Levack, MDmelissa.levack@vumc.orgMegan Coylewright, MD MPH FSCAImegan.coylewright@Hitchcock.org