Proceed with caution

Incremental improvements in stenting over the past several decades gradually transformed practice and patient care. Will the same be true for less invasive cardiac surgery?

Several cardiovascular societies recently released recommendations for PCI centers without backup surgery that are designed to ensure patient safety and quality outcomes. Successes on several fronts—less restenosis with drug-eluting stents, better medical care, physician and hospital sensitivity about overstenting and other advancements—have led to a decrease in the number of PCIs performed annually. The challenge for smaller centers is maintaining quality despite lower volumes.

Like PCI, volume may play an important role in the success of transcatheter aortic valve replacement (TAVR).

Planners for the upcoming American College of Cardiology scientific session talked about the potential impact of TAVR to change surgical practice at a recent press conference. TAVR will be the focus of one late-breaking clinical trial as well as several other presentations. More than 200 centers now offer TAVR, and many attendees want to see if and how patient selection and outcomes differ from the pivotal clinical trials.

Prediman K. Shah, MD, ACC.14 co-chair and director of the Oppenheimer Atherosclerosis Research Center and the Atherosclerosis Prevention and Treatment Center at Cedar-Sinai, predicted TAVR would become more widespread in the next several years as the technology improves and data on outcomes accrue. Cindy Grines, MD, vice president of academic and clinical affairs at the Detroit Medical Center Cardiovascular Institute, also pointed out that demand may diminish as the backlog of untreated patients with severe aortic stenosis eases.    

Cardiac surgeons are not likely to hit the unemployment lines because of TAVR, at least those who practice at a TAVR center. Preliminary analyses showed that TAVR centers experienced an increase in volume in both TAVR and surgical aortic valve replacement in 2012.

Like PCI, volume may play an important role in TAVR’s success. Some physicians involved in TAVR trials voice concern about an erosion in TAVR’s benefit with the addition of low-volume providers. TAVR is an expensive technology; if dissemination fails to show improvements then payers will balk. Patients in need may not have a say in the matter, unless they have the means to pay out of pocket.

Less invasive surgery is attractive. It has the potential, under careful stewardship, to transform practice and patient care.  

Candace Stuart

Cardiovascular Business, editor