Implications of Low-Risk TAVR on the Future of Cardiothoracic Surgery

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In March 2019, two randomized trials were published comparing surgical (SAVR) and transcatheter aortic valve replacement (TAVR) in low-risk patients with severe symptomatic aortic stenosis: the PARTNER-3 Trial (Mack, et al., 2019; ClinicalTrials.gov number, NCT02675114) and the Evolute Low Risk Trial (Popma, et al., 2019; ClinicalTrials.gov number, NCT02701283).

Filmed at the 2019 AATS Annual Meeting in Toronto, Canada, Tom C. Nguyen of the University of Texas Houston in the USA moderates a discussion on the strengths and weaknesses of these recently published trials, focusing on the implications that these studies have for surgeons. Dr Nguyen is joined by Joseph Lamelas of the University of Miami in Florida, Michael Reardon of the DeBakey Heart and Vascular Center in Houston, Joseph Bavaria of the University of Pennsylvania in Philadelphia, Michael Mack of the Baylor Health Care System in Plano, Texas, Vinod Thourani of the Medstar Heart and Vascular Institute in Washington, DC, and Richard Shemin of the University of California Los Angeles.

In addition to detailing key elements of the studies and the reported primary endpoints, the panelists discuss the importance of the heart team and the critical role that it will play going forward as surgeons work to ensure the right procedure is performed for each patient. The group emphasizes the need for appropriate training so that surgeons are proficient at TAVR and able to collaborate within the heart team.

Dr Bavaria reviews the rationale for reopening and revising the TAVR National Coverage Decision (NCD) from the US Centers for Medicare and Medicaid Services (CMS). Additionally, Dr Shemin recommends that every surgeon read the expert consensus document from the AATS, the ACC, SCAI, and STS (Bavaria, et al., 2019), emphasizing that the better informed surgeons are, the better they will be able to serve both their patients and the surgical profession. The panelists highlight work that was and is being done by the societies to share feedback for the NCD as well as to provide educational opportunities for surgeons interested in developing or enhancing their transcatheter skills.

Finally, each panelist provides their thoughts on the question: “Ten years from now, what will be the role of surgeons in treating structural heart disease?”

References

Bavaria JE, Tommaso CL, Brindis RG, et al. 2018 AATS/ACC/SCAI/STS expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter aortic valve replacement: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. 2019;157(3):e77-e111.

Mack MJ, Leon MB, Thourani VH, et al, for the PARTNER 3 Investigators. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380:1695-1705.

Popma JJ, Deeb GM, Yakubov SJ, et al, for the Evolut Low Risk Trial Investigators. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380:1706-1715.