In an earlier Consult QD post, Cleveland Clinic interventional cardiologist Amar Krishnaswamy, MD, asked the leaders of Cleveland Clinic’s Aortic Valve Center to spell out factors in their clinical decision-making when they weigh treatment options for patients with aortic valve disease.
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The panel-style discussion continues here, as the conversation dives deeper into two subtopics:
- Deciding how to manage patients with a degenerated aortic bioprosthesis
- How patient age factors into decision-making
This time Dr. Krishnaswamy’s questions are directed to the Aortic Valve Center’s surgical director, Douglas Johnston, MD, and interventional cardiology director, Samir Kapadia, MD.
Dr. Krishnaswamy: One group of patients encountered frequently at a referral center like ours are those with a failing bioprosthesis after prior surgical aortic valve replacement (AVR). We now have good options for these patients, either through reoperative surgery or by placing a transcatheter aortic valve within their failing surgical valve — so-called valve-in-valve TAVR. Dr. Johnston, how do you determine whether or not a patient is a good candidate for surgical reoperation?
Dr. Johnston: The first thing we look at is the patient’s overall surgical risk and whether there are other benefits to surgery besides just dealing with the failed valve. If there are more things that need fixing —mitral or tricuspid regurgitation, other aspects of heart disease that may benefit from surgery — that clearly argues for reoperation.
Age can also be key. If you have a young, healthy patient who has 20 or 30 years of healthy life ahead of them, uncertainty about the durability of transcatheter valves can be a drawback. Since we have good data on the durability of surgical valves out to 20-plus years, in that setting we’d lean more toward surgery.
In contrast, if you have a patient who’s very frail and has other medical problems, surgery might be an undue burden and valve-in-valve TAVR could be an excellent option.
Obviously many patients fall in the middle ground between these scenarios. That’s when having a comprehensive heart team approach like we have at Cleveland Clinic allows you to really get into the details of the patient’s case and draw on that broad expertise to make a decision that’s best for the particular patient.
Dr. Krishnaswamy: Dr. Kapadia, what are the considerations from a transcatheter valve perspective?
Dr. Kapadia: Size of the failed valve is most important — specifically, whether it’s big enough so that if you put a transcatheter valve inside it you can still have good hemodynamic response. Usually any surgical valve 21 mm or larger will raise no concern about a high hemodynamic gradient or patient-prosthesis mismatch. On the other hand, if the valve is smaller than 21 mm, then these are concerns to be considered.
The second consideration is the coronary artery anatomy, which is very important. Finally, the exact type of valve you put inside the failed valve is also a consideration — for instance, whether it’s a supra-annular valve or some other type. And of course we take into account any other anatomical issues in the heart or aorta that may need fixing, as Dr. Johnston mentioned. All these things are considered before we decide.
It’s important to point out that valve-in-valve outcomes are almost better than the outcomes of native valve TAVR. If you look at the TVT Registry and the valve-in-valve outcomes from the PARTNER 2 Registry, patients with native valve TAVR fare a little bit worse than those with valve-in-valve TAVR, in terms of mortality, stroke, paravalvular leak and pacemaker requirement.
Dr. Johnston: As valve-in-valve TAVR gets better and better, it’s now incumbent on surgeons to be mindful, every time we put a tissue valve into a patient, that this may be a needed option down the road. When we think about valve sizing, we’re very careful to put in a prosthesis that will be amenable to valve-in-valve, especially in younger patients. This is now a standard part of my discussion with any younger patient about getting a bioprosthetic valve. We don’t want to burn any bridges for the future, whether for open surgery or for valve-in-valve TAVR.
Dr. Krishnaswamy: That’s an important point. Let’s talk about younger patients more broadly. Dr. Kapadia, how does age factor into your decision-making for transcatheter versus surgical AVR?
Dr. Kapadia: Currently we are not using transcatheter valves in young, healthy patients who are surgical candidates outside the setting of a clinical trial. If the patient’s surgical risk is less than 2 or 3 percent by the STS score, we refer them for surgery. And keep in mind that at Cleveland Clinic the surgical risk is even lower than what is predicted by the STS score.
At the same time, we do have the option to randomize patients to either TAVR or surgical AVR in the PARTNER 3 trial involving patients with aortic stenosis at low surgical risk. The reason for this investigation is that we don’t yet know the durability of transcatheter valves and there’s uncertainty about potential procedural risks with TAVR in young patients. Those risks include a possible higher risk of pacemaker requirement and perhaps an increase in paravalvular leaks. Even if the leak risk is mild, long term it could have a deleterious effect relative to surgical AVR.
TAVR does look to be a promising option for these patients, so we offer appropriate younger individuals the chance to enroll in PARTNER 3. But we exclude patients who have a bicuspid valve, as we don’t yet have enough information to use transcatheter valves in that setting.
For a 14-minute video version of the full panel discussion from which this post was derived, see the video available here.