ACC.15: How 3 trials inform adult congenital heart disease practices

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 - Doctor and older patient

SAN DIEGO—Ami Bhatt, MD, co-director of the adult congenital heart disease program at Massachusetts General Hospital in Boston, shared her thoughts with Cardiovascular Business about sessions at the American College of Cardiology’s scientific session that she considered most exciting.

The interview, which took place March 15, has been edited for brevity.

CVB: What stood out for you today?

AB: We’ve seen one-, two- and three-year outcomes with the PARTNER I trial and they have looked equal to surgical aortic valve replacement. But to now see five years introduces a slightly different element because when we see older patients who are considering transcatheter rather than surgical AVR, one of the things we think about is what is their longevity.

To know five years gives us an opening to perhaps offer this to slightly more people. We are not talking just about mortality; we are really talking about all the morbidity that comes in the postoperative phase for these people. You want to be able to avoid that as well. You still have to meet criteria, but in terms of how long you will live, we can think about how long you will live well.

The second reason is especially exciting for me [because] I take care of people with congenital heart disease. There now are more adults than children with congenital heart disease. Bicuspid aortic valve is one of the most common congenital heart diseases. Up to 5 percent may have it; definitely 1 to 2 percent. That is well documented.

In that population, we don’t use the transcatheter. These are people who long term may require surgical aortic valve replacement at a younger age. If you are 20 when you get your first one, what will happen down the road? I wouldn’t suggest you use the TAVR now in a 20-year-old, [but] if that valve wears out at 55 rather than 85, could this be an option?

The more longevity we get out of a TAVR, the more options a congenital population has. That saves people a lot of morbidity because reoperations are hard.

What else?

AB: The DAPT trial analysis that came out today. Dr. [Robert] Yeh, who is one of my colleagues at Mass General and is the first author, did a beautiful presentation. The idea that we can look at acute coronary syndrome and determine that in these individuals, if we want to determine the benefit of dual antiplatelet therapy, it seems pretty clear that not only is it working on the culprit artery, but ischemia events, period, including the other arteries.

Why is that exciting? Now we say ischemia events happen less and it improves quality of life. As a physician, I want to know whether that risk of bleeding, which is slightly increased— granted it is major bleeding but not fatal bleeding—outweighs the risk of ischemia. They told me yes. Quality of life is better in individuals who have ischemia than it is in individuals who have bleeding. Bleeding really makes these people feel they are not living life the same way. That management is challenging.

If you look at the acute coronary syndrome and the nonacute coronary syndrome population, dual antiplatelet therapy is helpful in reducing ischemic events in both those groups, which was great. To hear patients as a whole, [say] ‘We prefer some ischemic events you can control, we don’t want the bleeding event.’ This is what I learned and it helps me talk with my patients about it.

Other favorites, but not from today: I think the PROMISE trial by Dr. [Pamela] Douglas was excellent. In that intermediate risk group that has angina and you don’t know what to do, the number of events was so low. That is reassuring for cardiologists. We wrestle with this. Then to know, whether you choose an imaging arm with CT angiography vs. a functional arm, both are probably the right way to go, is also reassuring.

I personally think CT is an excellent way to look at the coronary arteries because I take care of younger adults with heart disease. I also take care of people with premature atherosclerosis. If they have a strong family history, we start following them at a young age. For those individuals, to know that if I order a CT, I may end up intervening a little bit less unnecessarily.

A lot of patients with congenital heart disease need reinterventions in midlife. When they have a reintervention in midlife, one question we ask is, do we need to screen the coronaries? If we are going to go in and do heart surgery on you, I need to know if you have obstructive coronary disease and your story alone is not enough to tell me.