Transcatheter Aortic Valve Replacement at the Emory Structural Heart Disease and Valve Center

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Interview by Stephanie Wasek

We have learned to anticipate many of the common problems of performing hybrid procedures on the elderly: nutrition, delirium, fall risks and mobility limitations, anticoagulation risks and social needs (long-term and short-term rehabilitation). The post-op care (and the anticipation of problems before they occur) is critically important, as is patient selection and careful procedural techniques.

We have also gotten more aggressive with the evaluation and treatment of paravalvular leak (PVL). If patients are not progressing within the hospital stay or by one-month post-TAVR, we carefully re-assess the degree of PVL, which is often difficult, by transthoracic echo (TTE).

How has your approach to the TAVR procedure evolved over time?

Dr. Cribier has spent a lifetime understanding aortic stenosis, and taking a complex therapy and making it simple. We have adopted the same philosophy at Emory and continue to collaborate with Dr. Cribier and his team to this day.

I think one of the key collaborations between the two groups has been the use of balloon sizing of the aortic annulus to select transcatheter valve size. We have published two papers on this topic1,2, identifying the balloon used during the valvuloplasty as a valve sizer, exactly as a surgeon would use for traditional surgical AVR. We adopted a completely percutaneous approach by 2009 with the 22 French (Fr) and 24 Fr devices, and have minimized vascular screening to a non-contrast CT and lower-extremity angiogram (10 cc of contrast). In patients with renal insufficiency, we have decreased the total contrast use to 20 cc per procedure by using the echo and the pigtail catheter placed on the aortic valve to determine the valve plane and position. We have started transporting patients to a telemetry floor and have avoided ICU stays completely in some cases.  

What advice would you give to centers that are gearing up to begin a TAVR program?

The toughest period for a new TAVR center is the first 10 implants. The first 10 procedures should be successful, to gain the confidence of referring physicians and hospital staff. It is often tough to find 10 “perfect” patients for TAVR, especially early in one’s experience, and the temptation to try an implant in a non-ideal situation is very strong. It is important for new centers to resist this urge and send some of these patients for smaller devices and transapical approach in experienced centers that are part of clinical trials.  Also, it is important for new centers to evaluate and treat the patient with severe, symptomatic aortic stenosis efficiently, as delays can result in mortality.

Over time, a new center should expect the number of cases to grow. Organization is a critical part of these programs, and a smart TAVR nurse coordinator can help immensely in this area. Also, the team is only as strong as its weakest link. A hybrid program such as TAVR cannot be built on the back of only one cardiologist or one cardiac surgeon or one echocardiographer, regardless of skill level. The trick is to find all three, in one center, who are very capable and like working together.

References

  1. Babaliaros VC, Liff D, Chen EP, et al. Can balloon aortic valvuloplasty help determine appropriate transcatheter aortic valve size? JACC Cardiovasc Interv 2008 Oct; 1(5): 580-586.
  2. Babaliaros V, Junagadhwalla Z, Lerakis S, et al. Use of balloon aortic valvuloplasty to size the aortic annulus prior to implantation of a balloon-expandable transcatheter heart valve. JACC Cardiovasc Interv 2010 Jan; 3(1):114-118.
  3. Lerakis S, Babaliaros VC, Block PC, et al. Transesophageal echocardiography to help position and deploy a transcatheter heart valve. JACC Cardiovasc Imaging 2010;3(2):219-221.

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