TCT 2017: PCI, TAVR anniversaries spur forward-looking discussions

DENVER — Before the 29th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium kicked into full swing Oct. 30, a pair of doctors drew attention to two important anniversaries for interventional cardiology. The first PCI was performed 40 years ago and the first transcatheter aortic valve replacement (TAVR) was completed 15 years ago.

In his TAVR presentation Oct. 29, Martin B. Leon, MD, provided some comic relief with photos of Alain Cribier, MD, and his team as they performed the first in-human TAVR in 2002. Leon zoomed in closely on the clinicians’ faces, which appeared to be some mixture of apprehension and terror.

Of course, TAVRs are completed with much more confidence nowadays. Leon detailed the “explosive growth” of the technique, which he tied to a commitment to evidence-based medicine, ­­­­rapid technological advancement, simplification of the procedure and a “striking” reduction in complications.

Leon said more than 15,000 patients have enrolled in TAVR-based clinical trials over the last decade. More than 100,000 procedures are expected to take place this year and in 2025 more than 300,000 are projected—“a conservative estimate,” according to Leon.

“We should hopefully improve disease awareness and access to TAVR, especially in underserved populations and especially in situations where the economics make it unfavorable. This to me is problematic and we need to extinguish this confusion,” said Leon, the director of the Center for Interventional Vascular Therapy at Columbia University Medical Center/New York Presbyterian Hospital.

TAVR is generally used to treat patients with aortic stenosis who are at intermediate or high surgical risk. But now studies are ongoing in low-risk patients, Leon said, possibly leading to an even greater population that may benefit from the relatively new technique. In addition, TAVR accessory devices, such as those providing cerebral embolic protection, are now being studied.

“There are still important knowledge gaps with TAVR that have to be resolved,” he said. “This issue with valve leak we’re trying to understand. There are many ongoing studies right now and there may be some additional pharmacotherapy that would be appropriate in some of these patients.

“We realize that this is biological material so durability is a consideration. Ultimately all of these valves will have issues related to wear on the valve leaflets, so we have to understand durability and adapt excellent criteria for how to define durability in the heart valves.”

Spencer B. King III, MD, an interventional cardiologist at Emory Heart Center in Atlanta, began his 40th-anniversary discussion of coronary angioplasty by honoring some of its pioneers. King was one of the early adopters of the procedure now commonly referred to as PCI and gave a detailed rundown of some of the issues internists faced over the years and how technology and practice has advanced.

“A question for us in the future in interventional cardiology is, ‘Will medical therapy improve to the point that that will be first line and we will reserve interventional procedures for more complex coronary cases?’” he asked. “We’re all getting older, so we just have to do interventions on a lot older patients than we did before, because I don’t think it’s going to go away. My hope is that in the next 40 years, current therapies that we have today may become obsolete and become totally extinct, that they will be replaced by better solutions for coronary artery disease.”