Cath Lab Digest

The transcatheter aortic valve replacement (TAVR) program at Emory University Hospitals in Atlanta, Georgia, has completed over 400 TAVR procedures and is one of the highest-volume sites in the nation.

Can you tell us about the Heart Team partnership at the Emory Structural Heart Disease and Valve Center?

My introduction to transcatheter aortic valve replacement (TAVR) was via Peter Block, MD, FACC, who had done many of the early balloon aortic and mitral valvuloplasties in the United States. As a fellow under Dr. Block,  I was encouraged to pursue further training in structural heart disease and he helped me contact Alain Cribier, MD, so I could spend 2004 to 2005 training in France. This was a very exciting time, as only a few cases of TAVR had been performed by Dr. Cribier and his team, and I was his first American fellow. 

My passion for TAVR came from him. The TAVR project for me became very personal because it involved relationships between people — not only between me and the patients and their families, but also with my former mentors, Drs. Cribier and Block, trying to carry on their level of quality and service.

Upon my return to the United States, Dr. Block and I began working together as colleagues, building a large referral of structural heart disease patients to Emory, and re-started balloon aortic valvuloplasty in 2006. Around that time, I got a phone call from a young surgeon at Emory, Vinod Thourani, MD, who was talking about how important this technology was to him, how he loved valves and valve surgery, that he was going to China for a month to learn some catheter skills and asking whether we could make a team together. We formed a team made up of Robert Guyton, MD, the chief of surgery, Dr. Thourani, Dr. Block, and myself. Our first transfemoral implant was September 2007. In a year, we completed 30 implants and took a team trip to Leipzig, Germany, to watch Thomas Walther, MD, PhD, implant transapical valves.

Today, we have performed almost 400 TAVRs; Dr. Thourani and I have performed the majority of the implants. The team is incredibly efficient, with prompt implants, work-ups and turnarounds. We have added a considerable number of people to the team and have more help than in the early years, but Dr. Thourani and I still connect on every decision made, whether it is about the Emory Structural Heart Disease and Valve Center, or for a specifically tailored case with a complicated patient (which comes up quite frequently these days).

Our structure really works and is practical. One of the keys is that both cardiologists and surgeons are very passionate about TAVR and structural heart disease. We have learned from each other, and have been better as a whole than as individual parts. Our partnership has been unique because we are colleagues and friends, and have looked out for each other throughout the building process. It has also been important that our skill sets are complementary. In addition, it would have been hard to build a partnership without letting go of artificial boundaries and old traditions between surgeons and cardiologists.

Tell us about your TAVR clinic team. What dedicated resources do you have in place?

Our core TAVR clinic consists of two cardiologists (Dr. Block and me), two cardiac surgeons (Drs. Thourani and Guyton), and two TAVR coordinators (Patricia Keegan, NP, and Amy Simone, PA). We recently added two more cardiologists (Kreton Mavromatis, MD, and Chandan Devireddy, MD) and one more cardiac surgeon (Brad Leshnower, MD). Since 2007, we have had a cardiac fellow as part of the service (Mihir Kanitkar, MD), but we added cardiac surgical fellows last year (Tom Nguyen, MD, and Christian Shults, MD).

Perhaps one of the most important members of the team has been our echocardiographer, Stam Lerakis, MD, FAHA, FACC, FASE, FASNC, FCCP, who has really contributed a lot to interventional/procedural echo in the last few years. He has unlocked a lot of secrets for us in terms of sizing, paravalvular leak, transcatheter valve placement and problem solving. He reads the majority of our baseline and follow-up echos and did all the TAVR echos until last year, when we started performing TAVR at a second campus. He is also doing our cardiac CT, cardiac MRI and nuclear studies.

Also, until last year, we have had a dedicated sonographer (Sharon Howell, RDCS) and dedicated TAVR cath lab team (Kelly Broxton, RT(R)(CI), RCIS, and Jimmy Colgate, CVT EMT-P). We have one administrative assistant for the structural and valve center on each campus. The team is quite big now, with a very developed infrastructure.

In 2007, the TAVR clinic began with every patient seen the same day by the surgeon, cardiologist, and fellow, on one campus. This was very important, as we were learning from each other, and trying to set expectations for patients and patients’ families that would be agreeable to all parties involved in procedural planning. Since then, we have expanded to two campuses with TAVR coordinators, fellows, sonographers and echocardiographers, and hold clinic 3 to 4 days per week (new patients 2 days a week).

Currently, I run the TAVR clinic on one campus, while Dr. Thourani runs the TAVR clinic on the other campus. Once a week, previous patients and upcoming implants are reviewed by the heart team, and trouble-shooting and planning are done well before patients are scheduled for their procedures.