COMMENTARY

Can Minimally Invasive Surgical Aortic Valve Replacement Challenge TAVR?

Wayne B. Batchelor, MD, MHS; Tom C. Nguyen, MD

Disclosures

April 19, 2021

This transcript has been edited for clarity.

Wayne B. Batchelor, MD, MHS: Hello, everyone. I'm Wayne Batchelor. I'm the director of interventional cardiology research and education at the Innova Heart and Vascular Institute in Falls Church, Virginia. I'm joined here by Dr Tom Nguyen.

Tom C. Nguyen, MD: Thank you, Dr Batchelor; and thank you, Medscape, for hosting this. As a quick background, I'm a cardiothoracic surgeon. I'm the chief of cardiothoracic surgery here at UCSF.

Batchelor: We're lucky to have you on this call because you also have some interest in minimally invasive surgery, I understand. There's this whole other conversation going on right now about should we really be comparing TAVR (transcatheter aortic valve replacement) vs SAVR (surgical aortic valve replacement), or is the appropriate comparison TAVR vs so-called minimally invasive AVR? Maybe you can speak a little about the minimally invasive options that are available to our patients.

Nguyen: I'll start off with the disclosure that I'm a little biased because I do minimally invasive AVRs; I do minimally invasive mitral valve repair and replacements. But also, the caveat is that the adoption rate in the United States is roughly 25%-30%, give or take — ie, most surgeons in the US don't do minimally invasive. But I do know the data, and the data for minimally invasive are pretty compelling. And this is where it relates to TAVR. [Compared with SAVR] consistently, minimally invasive AVR has shown shorter length of stay, less blood transfusion, less time in the ICU, and faster recovery. This is where we see the competition with SAVR vs TAVR, but where minimally invasive is actually kind of in the middle, where you're actually approaching some of those numbers that you see with TAVR.

Unfortunately, the reality is that there have not been any good studies that compare minimally invasive AVR vs TAVR. There have been some subgroup analyses, but I have to admit that I think that it hasn't been done appropriately, and I think there is a huge role of potential to look at minimally invasive AVR vs TAVR in a very organized, randomized controlled fashion because in that sense, then we would have a lot more data. We have data on durability of the valve itself, we have data on the ability to implant the valve in a bicuspid, we have a lot more data about lower PVL (paravalvular leak) rates and heart block, etc. I think there's a lot more potential, but we need more information.

Batchelor: How do you at UCSF approach that patient? And what kind of conversations do you have?

Nguyen: In essence, when a patient comes in, in my conversation I exclude SAVR in the traditional sense of the sternotomy. When a patient comes in to my office, we usually have a discussion about TAVR vs minimally invasive AVR. And I'll be honest with you: When I sit down and talk to the patient about minimally invasive AVR vs TAVR, most of the time they are okay with getting a minimally invasive AVR. With surgery, what they're worried about is not necessarily how you do it, but about getting their chest cracked open, getting the sternum open. And when I have a conversation with them and tell them, "Hey, we can actually do the surgery through a small incision," 9 times out of 10 they're okay with it, especially if I tell them, "Hey, we're doing it in such a way that we have a lot of long-term data with a valve that we know is going to last this amount of time. We're going to assure that there should be minimal paravalvular leak, etc. " Usually they're amenable.

Batchelor: If surgery had really no difference in periprocedural complications in terms of atrial fibrillation, and very rapid recovery, I don't think any of these conversations would be nearly as difficult. Do you know of anything on the horizon that might advantage surgery in a way, besides what you've described (which is minimally invasive techniques), to get them home earlier, to get the recovery process going quicker, and to avoid the risk for periprocedural arrhythmias like atrial fibrillation and some of the rehospitalizations that we see?

Because when you look at cost-effectiveness, it turns out that TAVR looks pretty darn good. That's probably because of these issues related to recurrent admission and periprocedural arrhythmias, etc.

Nguyen: Right. I think the most promising thing on the horizon is a mechanical valve that's being developed that does not require any anticoagulation. How cool would that be? There are a couple of companies out there that are developing it, and it's under trial right now. So, imagine that scenario that you drew up before: A low-risk patient or a young patient wants something done, doesn't want to be on Coumadin, and wants something that lasts their entire life. Well, there's something that's out there that is in trial that might be able to do that. I do think that it could be a game changer if it does in fact end up working. That's what I'm now following very closely and seeing where that data pan out.

Batchelor: Not everyone is a Tom Nguyen in terms of offering the full gamut of therapies, right? So, you can offer minimally invasive, you're obviously involved in TAVRs and traditional open surgical AVRs. Some of what you're saying is actually extremely germane, but what thoughts do you have for the average surgeon who out there doesn't offer some of the newer techniques that you're describing?

Nguyen: For me, recognizing the potential role of transcatheter therapies —early on, I embraced it and was not necessarily a pundit of the transcatheter therapies. I think a lot of surgeons out there initially were critics of it, and eventually TAVR proved them wrong. It was a cycle, and before you know it, now we have a device that's actually pretty good and there's a big role for it. I think my first advice is that, as surgeons, we need to embrace the technology; we need to work very closely with our cardiology colleagues in a multidisciplinary fashion, in a heart team approach, to do what's best for patients.

Batchelor: It's unusual to be able to talk to someone who really can go 360 degrees around all of TAVR and SAVR and everything in between. I really learned a lot speaking to you.

Nguyen: It's refreshing to have a conversation with you as a cardiologist, and with me as a surgeon, because I think we bring something different to the table, and we're doing it with the intent of doing what's best for our patients. That's really important. Several other important take-home points are that transcatheter therapies for the aortic valve and for the mitral valve are here to stay. We need to learn more about it, but it's here to stay and we need to not fight it — we need to embrace it — but we need to know the data. And that goes for cardiologists and surgeons, but I actually would argue that as surgeons sometimes we need to know the data even more because surgeons are often the ones that are critical about protecting the technology. But you need to know the data to be critical of it. Again, it was a pleasure talking to you.

Batchelor: It was really great to talk to you, Tom, and I look forward to seeing what happens in the next 10 years, especially as we get some of these newer prostheses followed up for a longer period of time.

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