Starting a revolution?

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Kaitlyn Dmyterko, senior writer

“You say you got a real solution. Well, you know we'd all love to see the plan," sang the Beatles in their hit Revolution. This week at the annual Pediatric & Adult Interventional Cardiac Symposium (PICS-AICS), presenters went back and forth as to whether transcatheter aortic valve implantation (TAVI) will ever replace aortic valve replacement as the gold standard and whether a greater number of lower risk patients could be safely treated with TAVI in the future.

Eric M. Horlick, MD, of the Peter Munk Cardiac Centre in Toronto, stressed that TAVI will "revolutionize" cardiovascular medicine, suggesting that the procedure may transform how cardiovascular medicine is practiced. However, he did note that there is concern with the procedure after a high number of strokes were found with TAVI. He offered that in the future using filter devices could help prevent carotid embolization, which can lead to stroke.

Meanwhile, Raj Makkar, MD, of the Cedars-Sinai Medical Center in Los Angeles, said that there are a large number of patients with aortic stenosis (AS) that are not being treated with surgical aortic valve replacement (AVR). “This was true even when there was no TAVI available.” Because less invasive treatments are safer and add to patient satisfaction, he said that TAVI provides a good alternative to surgery.

Currently, only one out of five patients with severe AS receive aortic valve replacement and an estimated 30 to 50 percent of AS patients go untreated. “Why are the surgeons operating on only one out of five AS patients today despite the proven track record of surgery?” Makkar asked.

While that question remains unknown, Makkar said that results of PARTNER were promising and gave surgeons an alternative to the pain and suffering often associated with open heart surgery.

On the other side of the argument, Harold L. Lazar, MD, of the Boston Medical Center, said that the rates of stroke found within the PARTNER trial transcatheter arm remain a concern. “TAVI patients have higher risk of stroke, leaks and vascular complications,” said Lazar, who also offered that it will take a lot to get reimbursements for the procedure.

“TAVI is inferior to surgical AVR for the treatment of aortic stenosis,” concluded Lazar. “Factors favoring surgical AVR are fiscal accountability, overestimation of risk by current, outdated scoring systems and open reporting of TAVI outcomes to produce accountability.” Lazar urged that TAVI devices, which remain unapproved, should only be implanted in patients at a high-risk for surgery and decreased life expectancy.

The approved PARTNER II trial will evaluate whether TAVI is safe and effective in a lower risk population.

“You tell me that it's evolution. Well, you know we all want to change the world," the Beatles sang. While TAVI may currently become the great debate within medicine, will it change the treatment for AS patients and allow lower risk patients to be treated with less invasive measures? We'd welcome your thoughts on the subject. 

Kaitlyn Dmyterko, senior writer
Cardiovascular Business