乌鸦传媒

NEW ORLEANS -- Leaders in thoracic surgery reassured their colleagues that the future is bright if they approach aortic valve replacement and structural heart disease with a new mindset.

From the low-risk randomized trials to real-world datasets, transcatheter aortic valve replacement (TAVR) is doing well and will continue doing so, according to Joseph Bavaria, MD, of the University of Pennsylvania, Philadelphia, a past president of the Society of Thoracic Surgeons (STS), who was one of the first TAVR implanters in the U.S.

By volume, TAVR surpassed every type of SAVR in the U.S. for the first time in 2019. But that doesn't spell doom for surgical approaches, Bavaria stressed during a presentation at the here.

Bentall procedures were also up 15% annually and cases of SAVR with another concomitant procedure fairly flat or slightly up since 2012, he said, citing registry data.

The picture for surgery is therefore "better than I expected," even if the combination of SAVR plus coronary artery bypass grafting surgery went slightly down.

SAVR has going for it several things, according to Bavaria: a recent finding of zero deaths within two years (from the RECOVERY trial's ), and newer valves that can maintain 10-mm Hg gradients up to four years with "almost non-existent" severe patient-prosthesis mismatch and aortic insufficiency that is "basically non-existent with good surgery."

In contrast, there are several "nuances" that should give pause to the rise of TAVR -- namely the lack of improvement in stroke or pacemaker rates in recent years, and difficulties in bicuspid anatomy in terms of an 18% pacemaker rate and paravalvular leaks exceeding 12%, said Bavaria.

Moreover, younger patients continue to do better with mechanical surgical valves over the bioprosthetic ones in TAVR.

So what is required for future success for surgeons in aortic valve intervention?

Bavaria suggested really knowing the data and establishing a robust TAVR team and clinic to start. He also reminded the audience that concomitant SAVR with another procedure is expanding -- another reason for surgeons to set up valve clinics.

The future of structural heart disease treatment requires a formal multidisciplinary approach beginning during fellowship, said another presenter during the same STS session.

In the U.S., current training in the field comprises industry courses, proctors, international meetings, "on the job" training, and un-accredited structural heart fellowships (40 in interventional cardiology and 10 in cardiac surgery), according to David Fullerton, MD, the executive director of the American Board of Thoracic Surgery (ABTS).

"There's no standardized curriculum. Some are very superficial. It's not known what one can expect to learn going to any of these particular fellowships," he said. "The future requires a comprehensive approach, a more formalized approach to the education of the next generation."

Thus, ABTS is proposing a structural heart fellowship with a set curriculum. It will also create a third track during thoracic surgery residency, the "cardiac surgery" track, to better prepare surgeons for the structural heart space.

The fellowship would be accredited by the Accreditation Council for Graduate Medical Education and lead to board certification in structural heart disease. It is being designed to last one year and would train cardiac surgeons and cardiologists together after interventional cardiology fellowship or thoracic surgical residency, respectively, Fullerton noted.

"Structural heart disease is now a true sub-specialty within both cardiology and cardiac surgery," he reasoned. "It's not all about TAVR. The procedural success of TAVR has catalyzed an explosion in new technology in the last 5-7 years."

Of note is the cardiology community's mixed reaction to the structural heart fellowship: some leaders in interventional cardiology are "very enthusiastic" while others have their reservations, he acknowledged.

Nonetheless, Fullerton said he is "optimistic" that the new fellowship will be formalized and in place by next year.