TAVR’s Traditions & Transitions

Transcatheter aortic valve replacement (TAVR) has progressed at lightning speed. Some cardiologists now debate what may be getting lost amid this rapid change.

TAVR has experienced substantial improvements in the past few years. Operators have remarked about sleeker designs and greater functionality in today’s devices compared with first-generation valves. The use of CT imaging for sizing has made differences in outcomes, and physicians have a better understanding of processes and patient selection now. 

Our cover story focuses on TAVR in intermediate- and low-risk patients with severe aortic stenosis. To date, the FDA has approved devices for inoperable and high-risk patients while suitable lower-risk patients undergo surgical aortic valve replacement. No one wants to have their chest cracked open if they can have a less invasive procedure, though.

TAVR valves cost in the neighborhood of $30,000 and surgical valves much less. Payers may balk at the higher prices, which also take a bite out of margins. With only two vendors so far approved in the U.S., there is little pressure to lower costs, although that is expected to change with competition. Device cost is not the only avenue for savings, though. Some programs have edged into the black using less resource-intensive practices.

This minimalist approach was hotly debated at the Transcatheter Valve Therapies conference in Chicago in June. Among other streamlining protocols, minimalist TAVR uses local or conscious sedation, which allows extubation in the operating room and gets the patient up and about swiftly. That cuts down on length of stay, especially when intensive care is not in the picture.

TAVR was built on a heart team model, which emphasized contributions from surgeons, interventionalists, radiologists and others. In a minimalist approach, anesthesiologists take a back seat during procedures (but don’t necessarily disappear). Radiologists still play a role, especially in planning; some argued that an excellent preprocedural workup was even more important in a minimalist setting.

“The surgeon will be next.” Sometimes presenters issued the idea jokingly, other times not. Who needs to be present during a procedure to ensure an excellent outcome? Are all centers qualified to perform minimalist TAVRs? Is the driver cost savings, better patient outcomes, or both?

These questions likely will intensify—and need to be resolved—as TAVR slips into lower-risk categories.