Multisociety (AATS, ACCF, SCAI, and STS) Expert Consensus Statement: Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part 1: Transcatheter Aortic Valve Replacement

A scoping review to identify competencies for transcatheter cardiovascular procedures

OBJECTIVES

Transcatheter procedures are increasingly being recognized as a priority for cardiac surgeons and cardiac surgery trainees. The optimal method of teaching these procedures during residency training has not been established. We used an evidence-based approach to systematically review the literature and identify competencies to inform future paradigms of transcatheter training in cardiac surgery.

METHODS

A scoping review was conducted to retrieve relevant literature on the performance of transcatheter cardiovascular procedures, identify competencies required by surgical residents learning to perform these procedures, and develop a preliminary list of competencies for consideration during transcatheter training. MEDLINE, Scopus, and ERIC were queried until April 1, 2020, using a systematic search strategy. No limitations were placed on publication date or type.

RESULTS

A total of 1456 sources of evidence were retrieved. After deduplication and screening, there remained 33 that were included in the scoping review, published between 2006 and 2020. The distribution of publication types included 10 comparative studies (30.3% of total), 8 societal statements (24.2% of total), 5 surveys and 5 opinion articles (each 15.2% of total), 2 editorials and 2 descriptions of a simulator (each 6.1% of total), and 1 narrative review (3.0% of total). From these, a total of 400 items were identified and organized into 97 competencies.

CONCLUSIONS

Evidence on the competencies required to perform transcatheter cardiovascular procedures is available from a variety of sources. The identified competencies may be a useful resource for developing curricula and teaching transcatheter procedures to cardiac surgery residents.

Current status of transcatheter aortic valve replacement in India

Transcatheter aortic valve replacement (TAVR) has proven to be the cornerstone therapy for patients with severe aortic stenosis (AS). India is currently overburdened with AS, both rheumatic and non-rheumatic. Although TAVR has revolutionized the treatment of non-rheumatic AS it does offer a ray of hope for rheumatic AS in future. It is difficult to measure the actual burden of AS in India due to lack of epidemiological studies in this population. Variable estimates have been given indicating a large number of patients eligible for TAVR. Despite its enormous potential, TAVR is still beyond the reach of an average Indian citizen. The progress for TAVR in India remains rather slow with obstacles at multiple levels. These include high costs, lack of coverage by insurance companies, continuous ignorance in government policies, lack of sufficient trained TAVR performing operators and lack of healthcare providers trained in post-TAVR care. Additionally, unique anatomical factors such as smaller body surface area, smaller annulus size, low coronary ostia take-off, smaller calibre of iliac and common femoral arteries pose unique challenges in terms of need for smaller hardware and increased chances of complications. It is crucial that the policy makers and healthcare personnel wake up to the benefits of this innovation and take appropriate steps to ease the dissemination of TAVR across the country.

Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons Survey

BACKGROUND

The Society of Thoracic Surgeons (STS) surveyed cardiothoracic surgeon participants in its Adult Cardiac Surgery Database (ACSD) to learn the extent of surgeon involvement in transcatheter aortic valve replacement (TAVR) procedures.

METHODS

An electronic survey was delivered to 2,594 surgeons in June 2016. When the survey closed 2 weeks later, 487 completed surveys had been submitted for a response rate of 18.8%.

RESULTS

Among the 487 participants in the ACSD who responded to the survey, 410 (84.2%) reported that TAVR was performed at their institutions. Approximately three-quarters reported that they performed TAVR procedures as part of a heart team (77.5%; 313 of 404), cardiologists and cardiothoracic surgeons were jointly responsible for TAVR referrals (83.7%; 339 of 405), and TAVR programs were administered either jointly by the cardiology and cardiac surgery departments or exclusively by the cardiac surgery department (73.3%; 297 of 405). A majority were involved in the pre-, intra-, and postoperative care of patients undergoing TAVR, with 91.4% (370 of 405) reporting participation in multidisciplinary meetings, at least 50% regularly performing technical aspects in 10 of 11 conduct of operation categories, and 86.6% (266 of 307) caring for patients undergoing TAVR after the procedure.

CONCLUSIONS

Cardiac surgeons in the United States are active participants in the management of patients with aortic stenosis as part of the heart team. The STS survey found that not only were they actively involved in the treatment decision-making process but they also played a significant role in the valve procedure, including deployment and postprocedural care. The heart team model continues to evolve and should be expanded into other areas of structural heart disease.

Can predilatation in transcatheter aortic valve implantation be omitted? - a prospective randomized study

BACKGROUND

The use of a balloon expandable stent valve includes balloon predilatation of the aortic stenosis before valve deployment. The aim of the study was to see whether or not balloon predilatation is necessary in transcatheter aortic valve replacement (TAVI).

METHODS

Sixty consecutive TAVI patients were randomized to the standard procedure or to a protocol where balloon predilatation was omitted.

RESULTS

There were no significant differences between the groups regarding early hemodynamic results or complication rates.

CONCLUSIONS

TAVI can be performed safely without balloon predilatation and with the same early results as achieved with the standard procedure including balloon predilatation. The reduction in the number of pacing periods required may be beneficial for the patient.

Imaging of cardiac valves by computed tomography

This paper describes "how to" examine cardiac valves with computed tomography, the normal, diseased valves, and prosthetic valves. A review of current scientific literature is provided. Firstly, technical basics, "how to" perform and optimize a multislice CT scan and "how to" interpret valves on CT images are outlined. Then, diagnostic imaging of the entire spectrum of specific valvular disease by CT, including prosthetic heart valves, is highlighted. The last part gives a guide "how to" use CT for planning of transcatheter aortic valve implantation (TAVI), an emerging effective treatment option for patients with severe aortic stenosis. A special focus is placed on clinical applications of cardiac CT in the context of valvular disease.