Know your heart surgery risk category. Choose wisely between TAVR (TAVI) and open heart surgery. Aortic stenosis. 3
Choosing TAVR / TAVI or open heart surgery to replace aortic valve can be difficult. Leading cardiologist explains how to make procedure choices in aortic stenosis treatment. How to assess surgical risks for patients who are thinking about the transcatheter aortic valve replacement? Dr. Anton Titov, MD. How to choose between TAVI and classical open-heart surgery aortic valve replacement? Dr. Jeffrey Popma, MD. Yes. The assessment of surgical risk really starts with a multidisciplinary team. It includes heart surgeons, interventional cardiologists, non-invasive cardiologists, and nurse practitioners. Dr. Jeffrey Popma, MD. In patients with aortic stenosis who are elderly, the fundamental goal right now is to say this. “Are they at elevated risk for surgery?” This technically means the 30-day mortality rate over 3%. Then we arbitrarily classify patients into high-risk and extreme risk. Dr. Anton Titov, MD. Some patients shouldn’t get anything at all. Dr. Jeffrey Popma, MD. So now there has been approval for two aortic valves for transcatheter replacement. It is the Evolut TAVR aortic valve with the Medtronic core valve system. There is also the Sapien 3 TAVR valve with the Edwards system in intermediate risk patients. Some of those differentiations in patients become a little bit arbitrary. Because all the patients would be suitable for TAVR / TAVI. Dr. Anton Titov, MD. But the parameters that we look at is a standardized risk. It is so-called the STS predictive risk mortality. Dr. Jeffrey Popma, MD. That’s a benchmark. It tells us what the surgical risk of the patient would be. Then we look at a variety of different parameters related to the patient’s frailty, to their disability. Dr. Anton Titov, MD. Can patients care for themselves at home? What are patient’s co-morbidities? Do they have bad lung disease or bad liver disease? Finally, we have a more contemporary method to start looking at the aortic valve anatomy. Patients that have a very small aortic annulus under 20 millimeters. Dr. Anton Titov, MD. For them maybe a transcatheter aortic valve would be more favorable than a surgical valve. Dr. Jeffrey Popma, MD. This helps to avoid a syndrome called “prosthesis-patient mismatch”. We use a lot of heart imaging methods. Dr. Jeffrey Popma, MD. We perform surgical evaluation, cardiologist’s evaluation, and general cardiologist’s imaging evaluation. We come up with what the patient’s risk of aortic valve replacement procedure is. Now the only frontier that we really have left to prove for TAVR superiority are the lower risk patients. We have to identify best aortic valve replacement procedure in patients with congenital abnormalities. Dr. Anton Titov, MD. For example, bicuspid aortic valve disease.
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