Options for aortic valve replacement (AVR) have never been greater than they are today. But abundant options also bring a multitude of treatment considerations to be weighed.
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To sort through these considerations, Consult QD convened a panel discussion with leaders of Cleveland Clinic’s Aortic Valve Center — its surgical director, Douglas Johnston, MD; interventional cardiology director, Samir Kapadia, MD; and imaging medical director, Leonardo Rodriguez, MD. The discussion was moderated by Cleveland Clinic interventional cardiologist Amar Krishnaswamy, MD.
Dr. Krishnaswamy: Dr. Johnston, what are the options that patients with aortic valve disease now have, and what factors do you weigh in choosing an incision type for a given patient?
Dr. Johnston: The most important thing to think about is the safety of the procedure. We have a highly tailored approach here in terms of which incision we select for a patient. It really depends on the patient’s own healthcare goals and objectives. We start with that along with the specific problems that need to be fixed in the heart.
Fortunately, for the many patients with isolated valve disease, there are a number of small-incision options. A lot of our patients, especially young ones with bicuspid valves, just need an aortic valve or an aortic valve with ascending aorta repair. Most of these patients can be treated in one of two ways — via a small incision between the ribs or a small sternotomy incision, typically under three inches. Each approach improves recovery time and makes patients happy about avoiding a bigger incision.
For patients who need a lot of work done in addition to the aortic valve, I point out that the difference in recovery time with larger incisions is not that big. I emphasize that most patients with aortic valve disease feel so much better after surgery regardless of the operation’s invasiveness.
So the priority is fixing what’s wrong and giving the patient a safe, effective operation. When we can do that with a small incision, which we often can, that’s a great bonus.
Dr. Krishnaswamy: Transcatheter AVR [TAVR] is an option for a lot of patients. There’s been enthusiasm around recent data on applying TAVR to groups at lower and lower surgical risk. We’ve also seen data showing that some complications from the early days of TAVR — such as stroke and paravalvular regurgitation — have come down. Dr. Kapadia, how do these recent data inform our practice at Cleveland Clinic?
Dr. Kapadia: Last year we did close to 400 TAVR procedures, and most were still in patients at high surgical risk. But the recent data leave no question that TAVR is equal to surgical AVR in intermediate-risk patients, who generally are those with STS scores of about 4 to 8 percent.
So we bring together a comprehensive heart team — including cardiac surgeons, interventionalists, cardiac imaging specialists and other cardiologists — to analyze the risk and benefit of TAVR versus surgical AVR for each patient on an individual basis, to guide the care in each case.
If you look at the recent data — namely, the PARTNER 3 and SURTAVI trials — the risks of both stroke and paravalvular leak with TAVR have fallen considerably from the early experience. With that in mind, I think TAVR is very similar to surgical AVR in outcomes and that TAVR is an outstanding option for intermediate-risk patients. Valve durability with TAVR is something we still need to look at as time progresses.
We also need to reduce the risks of pacemaker requirement with TAVR, especially for younger patients. The risk can be between 10 and 25 percent, depending on the TAVR device.
Dr. Krishnaswamy: Dr. Rodriguez, as a specialist in imaging, what are your considerations when you refer a patient for treatment of aortic valve disease?
Dr. Rodriguez: We need to take into account the individual patient’s surgical risk, as noted, as well as other associated pathology. In that regard, accurate diagnosis may include not only the severity of the patient’s aortic valve disease but also any associated mitral and tricuspid valve disease, the size of the ascending aorta, and other factors. All this must be considered when deciding between surgery and a transcatheter option for a given patient. We do a lot of workup to gain complete understanding of what pathology an individual patient has.
Dr. Kapadia: What about when a patient is referred for severe aortic stenosis but they don’t have a lot of symptoms? At what point do we decide they need corrective therapy? Is the needle moving toward intervening for more asymptomatic patients, or are we still waiting for symptoms?
Dr. Rodriguez: First we need to be sure the patient is truly asymptomatic. Some patients don’t report symptoms, but if you push them a little further, significant symptoms may become apparent. We often use a stress test on these patients to try to elicit symptoms, as well as electrocardiographic changes. This is a very important part of our workup.
Second, it’s true that as mortality from AVR improves, we tend to use it in patients who are less and less symptomatic. There are some guidelines in this regard — for instance, patients with a tiny valve orifice or whose valve is severely calcified may be considered for AVR even if they don’t yet have any symptoms.
And as we’ve said earlier, a lot depends on the surgical risk profile. The lower a patient’s surgical risk, the earlier we tend to intervene. But for aortic stenosis patients in whom we do not yet intervene, very close monitoring is critical. We see those patients a couple of times a year, with repeated studies, always asking the same questions: How are you doing? Have you developed new symptoms? If they have, we promptly refer to the interventional or surgical team for quick treatment.
Dr. Johnston: That point can’t be emphasized enough. It’s important to remember that there are still many patients who are undertreated for aortic valve disease. While we have these amazing therapies available, we still see patients who present with very advanced disease and we still see patients who die of aortic stenosis without treatment. It’s not widely known that aortic stenosis, once symptomatic, has a survival rate that’s worse than many cancers, yet we still see patients who are treated late.
One of our jobs is to get out the message of how advanced our therapies for aortic valve disease are and how well patients do with those therapies. Some patients will still be watched while others get surgery and others get TAVR. The best we can do is get people in the door, get them evaluated with echocardiograms, get them to see a comprehensive heart team and start the process.
For more of this conversation — including discussion of treating failed aortic bioprostheses and how to factor in patient age — click here. For a 14-minute video version of the full panel discussion, see the video here.