The state of transcatheter aortic valve implantation training in Canadian cardiac surgery residency programs

Results and insights after 413 TAVI procedures performed by cardiac surgeons on their own

OBJECTIVES

Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own.

METHODS

This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database.

RESULTS

A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality.

CONCLUSIONS

The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

Future of cardiac surgery, introducing the interventional surgeon

BACKGROUND

The swift advances in interventional cardiology combined with the increasing risk of cardiac surgical procedures resulted in diminishing volume of coronary and valvular surgery and affected the future of cardiac surgery service and training. Application to cardiac surgery training programs have steadily declined. This cross-sectional study aimed at identifying main weakness facing cardiac surgery and advocating some recommendations to improve the status of current and future of cardiac surgery.

METHODS

Cross-sectional study was authorized by the institutional review board of King Abdulaziz University and performed among cardiac surgeons and cardiologists in the Kingdom of Saudi Arabia, from May to June 2021. Data were collected by sending questionnaires through email to cardiac surgeons and cardiologists in different cardiac centers all over Saudi Arabia. Out of 200 emails sent to our participants only 55 who responded.

RESULTS

A total of 55 doctors who participated in the study have completed the self-administered questionnaire by electronic mail. Seventy-six percent of the respondents are cardiac surgeons and 24% are cardiologists. Most of the respondents (72.7%, 63.6%) think that the volume of coronary and valvular cardiac surgery patients nowadays is less than before compared to invasive cardiology patients. Most of the respondents (91%) think that coronary cardiac surgery is better than invasive cardiology in left main disease and complex lesions but carries higher risk. Sixty-nine percent of the respondents think that one cardiac center in each city according to the population will provide better cardiac health services compared to small cardiac units.

CONCLUSION

In the recommendations to improve the future of cardiac surgery, 83% of the respondents agree that residents training in cardiac surgery should be modified to add at least one extra year of training in the Catheterization Laboratory (Cath lab) procedures including coronary, valvular, aortic and arrhythmia, thus introducing the interventional surgeon.

Pan-Canadian initiative on Fundamental Competencies for Transcatheter Cardiac Surgery: A modified Delphi consensus study

OBJECTIVE

Transcatheter cardiac procedures have generated increasing interest in trainees and training programs alike. Using the modified Delphi method, we sought to clarify the transcatheter competencies that cardiac surgery residents should be expected to attain by the completion of training.

METHODS

Individuals with expertise in transcatheter structural heart and aortic procedures were recruited across Canada. A questionnaire was prepared using a 5-point Likert scale. During 2 rounds, participants rated the competencies that they thought cardiac surgery residents should be required to achieve to perform transcatheter procedures. Data were analyzed and presented to participants between rounds. Competencies rated 4 or higher by at least 80% of respondents after the second round were considered fundamental to transcatheter cardiac surgical training.

RESULTS

A total of 46 individuals participated in the study, including 23 cardiac surgeons, 17 interventional cardiologists, and 6 vascular surgeons. Participants with relevant experience performed a median of 75 (interquartile range, 40-100) transcatheter aortic valve implantations in the prior year as primary or secondary operator and 15 (interquartile range, 11-35) thoracic endovascular aortic repairs in the prior 2 years as primary operator. Median clinical and teaching experience consisted of 13 (interquartile range, 7-19.5) years in practice and 8.5 (interquartile range, 5-15) residents taught per year, respectively. Of the included competencies, 53 were considered fundamental to transcatheter cardiac surgical training.

CONCLUSIONS

The identified fundamental competencies can be used to develop educational strategies during transcatheter cardiac surgery training. Future efforts should focus on collecting evidence for their validity.

Two-year outcomes from the PARTNER 3 trial: where do we stand?

PURPOSE OF REVIEW

The PARTNER 3 trial was conducted to compare outcomes after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve and surgical aortic valve replacement (SAVR) in individuals at low surgical risk with aortic stenosis. Recently reported rates of death, stoke and valve thrombosis in the TAVR arm have raised concerns about the longevity of this intervention in low-risk individuals. It is incumbent on all members of the Heart Team to understand the potential consequences of these findings.

RECENT FINDINGS

TAVR was initially superior to SAVR at 1 year for a primary composite endpoint of death, stroke and rehospitalization. Results at 2 years now indicate noninferiority. Potential causative factors, comparisons with other transcatheter valves and implications for patients, providers and trainees are explored. Recommendations are additionally provided regarding TAVR and SAVR in individuals with aortic stenosis.

SUMMARY

Concerns regarding the longevity of TAVR in low-risk individuals notwithstanding, results from PARTNER 3 indicate that TAVR is at least noninferior to SAVR out to 2 years. Longer follow-up will be required to determine whether these newly founded concerns are justifiable.

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.

Impact of Operator Characteristics on Outcomes in Transcatheter Aortic Valve Replacement

BACKGROUND

Operator characteristics and outcome relationships have not been evaluated at the individual operator level.

METHODS

From New York State Department of Health Statewide Planning and Research Cooperative System, 5896 elective transfemoral transcatheter aortic valve replacement (TAVR) procedures performed by 161 operators between 2012 and 2016 were analyzed. We examined the following characteristics of the primary operator: specialty (surgery vs cardiology), sex, medical school location, experience of cardiology practice, interventional cardiology credentialing, past-year TAVR volume, and first year performing TAVR in New York State. The primary outcome was a composite of inhospital mortality, stroke, and acute myocardial infarction.

RESULTS

After adjusting for patient and other provider characteristics, there was no significant difference in the risk of major events between surgeons and cardiologists in performing TAVR (3.4% vs 3.6%, P = .60), between male operators and female operators (P = .80), and between operators who graduated from a US medical school and operators educated outside the United States (3.4% vs 3.6%, P = .73). In the subgroup analysis, interventional cardiology credentialing was not significantly associated with the inhospital major events (odds ratio 1.03; 95% confidence interval, 0.56 to 1.88; P = .80).

CONCLUSIONS

Primary operator specialty and other characteristics for TAVR were not associated with a difference in risk-adjusted inhospital outcomes. That may be due to the heart team model that allows proceduralists of different backgrounds to lend their expertise to the procedure.