James Antonios, Class of 2021
For those suffering from aortic stenosis (calcification of aortic valves), a decrease in blood flow to the body may be the result. This causes symptoms of lightheadedness and angina. The two major alleviations for such a problem comes in the form of either Surgical Aortic Valve Replacement (SAVR) or the newly developed less invasive technique, Transcatheter Aortic Valve Replacement (TAVR). Much debate occurs within the field, regarding which is more beneficial to high-risk patients. SAVR involves an open heart surgery, up to 12 hours or more in the operation room. However, TAVR is a less complicated, minimally invasive procedure that allows the insertion of a catheter into the femoral artery next to the groin and allows the indirect replacement of the aortic valve(s). (1)
As the discussion continues, some dichotomy is found between mortality and complication rate. According to surgeon-led TAVR program data from 2018, 90% of TAVR cases performed did not have any complication incidence. It is surprising to note that this suggests a difference between cardiologist-led and cardiac surgeon-led TAVR procedures. Although TAVR is a minimally invasive procedure that does not require a cardiac surgeon to operate, Dr. Okoh, MD of Newark Beth Israel Medical center notes that it is “pretty clear that when you have a cardiac surgeon involved actively, you really have really good outcomes with TAVR.” This begs the question of whether further training is required for TAVR, as cardiac surgeons are subjected to more years of residency that interventional cardiologists, who usually perform TAVRs. (2)
But, the low complication rate does not paint a full picture. Other studies have found a high readmission rate with patients undergoing TAVR. In fact, according to the STS/ACC TVT registry, approximately 60% of TAVR patients are readmitted within the first 90 days. One explanation is given by a study by Vemulapalli et al., which suggested that fragmented care not only accounted for readmission but also mortality rate. At a state level, those with higher TAVR output had lower fragmentation rates and vice versa. In some cases, this was linked to relative Medicare volume of patients, and the coverage offered. These readmissions, however, were not due to unrelated causes. The investigation found that 52% were associated with cardiovascular comorbidities. Thus, these patients are going to the nearest available hospitals, regardless of TAVR specialty, to seek immediate help, placing them at a higher mortality risk. (3)
Furthermore, in a meta-analysis performed by Vlahakes et al., it was found that using randomized controlled trials, TAVR patients were significantly associated with all-cause death, and other cardiovascular related complications (atrial fibrillation, acute kidney injury). Nevertheless, compared to SAVR, a higher percentage of these patients required permanent pacemaker implantation with moderate to severe paravalvular leak. However, there exists a flaw in this study. It included both low-risk and high-risk patients with aortic stenosis. Therefore, there is variability in the data that can be explained by other causes than TAVR vs. SAVR. In fact, TAVR is generally reserved for high-risk patients who cannot risk undergoing an open heart surgery. (4)
Surprisingly, for just high-risk patients, Abdelgawad et al. showed no significant advantage of TAVR over SAVR in survival rate. (5)
What can be gleaned from all this information? Firstly, it is apparent that this TAVR vs. SAVR is still an underdeveloped field, with many experimental flaws and factors that can affect results. Secondly, there is a conflict of interest, not just on a hospital level between surgeon and cardiologist, but also the companies that market the TAVR procedure. TAVR is an expensive technique that requires the presence of many hospital personnel. The actual catheter device, made by such corporations as Edwards Lifesciences presents a dilemma: is the device beneficial, or is its appeal fueled by corporate synergy? This also displays a socioeconomic disadvantage to underprivileged populations who cannot afford such an expensive procedure. However, this apprehension may also just be unwarranted. Nevertheless, to definitively answer the question of TAVR vs. SAVR needs more research and clinical controlled trials.
References
1.https://www.mainlinehealth.org/blog/2018/06/11/savr-vs-tavr
2.https://www.tctmd.com/news/tavr-related-complications-high-resource-use-decreasing-surgeon-led-program?utm_source=TCTMD&utm_medium=email&utm_campaign=TAVRNewsletter0219
3. https://www.tctmd.com/news/fragmented-tavr-care-common-linked-death-and-readmission?utm_source=TCTMD&utm_medium=email&utm_campaign=TAVRNewsletter0719
4.https://www.acc.org/latest-in-cardiology/journal-scans/2019/09/16/15/45/transcatheter-versus-surgical-avr-in-low-risk
5.https://pubmed.ncbi.nlm.nih.gov/31596707-a-comparative-study-of-tavr-versus-savr-in-moderate-and-high-risk-surgical-patients-hospital-outcome-and-midterm-results/
Image Address: 80745.jpg
As the discussion continues, some dichotomy is found between mortality and complication rate. According to surgeon-led TAVR program data from 2018, 90% of TAVR cases performed did not have any complication incidence. It is surprising to note that this suggests a difference between cardiologist-led and cardiac surgeon-led TAVR procedures. Although TAVR is a minimally invasive procedure that does not require a cardiac surgeon to operate, Dr. Okoh, MD of Newark Beth Israel Medical center notes that it is “pretty clear that when you have a cardiac surgeon involved actively, you really have really good outcomes with TAVR.” This begs the question of whether further training is required for TAVR, as cardiac surgeons are subjected to more years of residency that interventional cardiologists, who usually perform TAVRs. (2)
But, the low complication rate does not paint a full picture. Other studies have found a high readmission rate with patients undergoing TAVR. In fact, according to the STS/ACC TVT registry, approximately 60% of TAVR patients are readmitted within the first 90 days. One explanation is given by a study by Vemulapalli et al., which suggested that fragmented care not only accounted for readmission but also mortality rate. At a state level, those with higher TAVR output had lower fragmentation rates and vice versa. In some cases, this was linked to relative Medicare volume of patients, and the coverage offered. These readmissions, however, were not due to unrelated causes. The investigation found that 52% were associated with cardiovascular comorbidities. Thus, these patients are going to the nearest available hospitals, regardless of TAVR specialty, to seek immediate help, placing them at a higher mortality risk. (3)
Furthermore, in a meta-analysis performed by Vlahakes et al., it was found that using randomized controlled trials, TAVR patients were significantly associated with all-cause death, and other cardiovascular related complications (atrial fibrillation, acute kidney injury). Nevertheless, compared to SAVR, a higher percentage of these patients required permanent pacemaker implantation with moderate to severe paravalvular leak. However, there exists a flaw in this study. It included both low-risk and high-risk patients with aortic stenosis. Therefore, there is variability in the data that can be explained by other causes than TAVR vs. SAVR. In fact, TAVR is generally reserved for high-risk patients who cannot risk undergoing an open heart surgery. (4)
Surprisingly, for just high-risk patients, Abdelgawad et al. showed no significant advantage of TAVR over SAVR in survival rate. (5)
What can be gleaned from all this information? Firstly, it is apparent that this TAVR vs. SAVR is still an underdeveloped field, with many experimental flaws and factors that can affect results. Secondly, there is a conflict of interest, not just on a hospital level between surgeon and cardiologist, but also the companies that market the TAVR procedure. TAVR is an expensive technique that requires the presence of many hospital personnel. The actual catheter device, made by such corporations as Edwards Lifesciences presents a dilemma: is the device beneficial, or is its appeal fueled by corporate synergy? This also displays a socioeconomic disadvantage to underprivileged populations who cannot afford such an expensive procedure. However, this apprehension may also just be unwarranted. Nevertheless, to definitively answer the question of TAVR vs. SAVR needs more research and clinical controlled trials.
References
1.https://www.mainlinehealth.org/blog/2018/06/11/savr-vs-tavr
2.https://www.tctmd.com/news/tavr-related-complications-high-resource-use-decreasing-surgeon-led-program?utm_source=TCTMD&utm_medium=email&utm_campaign=TAVRNewsletter0219
3. https://www.tctmd.com/news/fragmented-tavr-care-common-linked-death-and-readmission?utm_source=TCTMD&utm_medium=email&utm_campaign=TAVRNewsletter0719
4.https://www.acc.org/latest-in-cardiology/journal-scans/2019/09/16/15/45/transcatheter-versus-surgical-avr-in-low-risk
5.https://pubmed.ncbi.nlm.nih.gov/31596707-a-comparative-study-of-tavr-versus-savr-in-moderate-and-high-risk-surgical-patients-hospital-outcome-and-midterm-results/
Image Address: 80745.jpg
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