Surgeons Actively Involved in All Aspects of TAVR

STS News, Spring 2017 -- An STS survey on transcatheter aortic valve replacement (TAVR) shows that cardiac surgeons are involved in all facets of managing patients with aortic stenosis.

“These results are exciting,” said Thomas E. MacGillivray, MD, STS Treasurer. “Not only are cardiac surgeons actively participating during the preoperative and intraoperative phases of TAVR, but they also are involved in the postoperative care of TAVR patients.”

Last summer, led by 2016-2017 President Joseph E. Bavaria, MD, the Society surveyed surgeon participants in the Adult Cardiac Surgery Database to learn the extent of their involvement in TAVR. Approximately 500 surgeons completed the survey. The results were presented at the STS Annual Meeting in Houston and are available online in The Annals of Thoracic Surgery.

Among the respondents whose institutions offered TAVR, 84% said that they were involved in the heart team. In addition, more than three-quarters (77.5%) said that their TAVR programs were either jointly administered by cardiology and cardiac surgery divisions/departments or administered exclusively by cardiac surgery.

“I was surprised but pleased to see that a majority of patients were managed by some sort of combination of cardiac surgeons and cardiologists,” explained Dr. Bavaria. “I didn’t expect it to be such a team effort.”

STS Director-at-Large Vinod H. Thourani, MD agreed: “When we started the original PARTNER trials—the goal being partnering cardiology and cardiac surgery together—I was concerned that we would lose some of the team momentum when TAVR was more widely adopted. This survey shows that we are doing really well; cardiologists and cardiac surgeons are working together at three out of four centers.”

The survey also looked at surgeon involvement in 11 technical components of the operation, from access to valve placement, positioning, and closure (see graph). “It was interesting to me that at least 50% of respondents were involved in every one of those conduct of operation time points, except for operating the endovascular table,” said Dr. Bavaria.

2016-2017 STS President Joseph E. Bavaria, MD released the results of the STS TAVR Survey at the Annual Meeting in Houston.

Expanding the Heart Team Approach

Now that the paradigm has been set for the heart team approach in the treatment of aortic valve disease, Drs. Bavaria, MacGillivray, and Thourani are advocating for expanding the heart team concept to other areas of structural heart disease.

“We have a proven proof of principle that the team concept works and works well,” said Dr. MacGillivray. “Cardiac surgery is the quintessential medical team sport. We have multidisciplinary teams that take care of patients for all kinds of cardiac problems. The natural place is for a patient to rely on a cardiac team that is set up to manage patients with all kinds of comorbidities and other problems.”

In some centers, interventional cardiologists and cardiac surgeons routinely work with heart failure specialists. Dr. Thourani said that he’s involved in early feasibility trials where an imager also is part of the heart team. “We need to make sure that surgeons and cardiologists who aren’t as familiar with some treatment options have the support they need from other areas. We have an expanded team that is now looking into new mitral and tricuspid valve technologies.”

To see the full survey results, access “Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons Survey” in The Annals of Thoracic Surgery. A video roundtable featuring Drs. Bavaria, MacGillivray, and Thourani discussing the results is available. Dr. Bavaria’s Annual Meeting presentation is available via Annual Meeting Online in General Session II.