PHILADELPHIA, PA — Surgeons are involved with cardiologists at all stages of transcatheter aortic-valve replacement (TAVR) as part of a multidisciplinary approach, suggest survey findings said to show that the heart-team approach for this procedure has been a success.[1]
Surveying almost 500 US cardiac surgeons, the Society of Thoracic Surgeons (STS) found that the vast majority were involved in the TAVR heart team alongside cardiologists, with more than 85% of those continuing to care for patients after the procedure.
The report's lead author, Dr Joseph E Bavaria (Hospital of the University of Pennsylvania, Philadelphia), a past president of the STS, said he was "surprised but pleased to see that a majority of patients were managed by some sort of combination of cardiac surgeons and cardiologists."
In an STS public statement about the survey, Bavaria said, "I didn't expect it to be such a team effort."
The survey's findings are "proof of principle" that the heart-team concept works for TAVR, according to report coauthor Dr Thomas E. MacGillivray (Houston Methodist Hospital, Texas), also commenting in the STS statement.
Surveys of this kind are important because they "get across, somewhat broadly and with the caveats of survey responsiveness, etc, the extent to which the surgeons are involved in these cases," Dr Ajay Kirtane (New York-Presbyterian Hospital/Columbia University Medical Center, NYC) told heartwire from Medscape.
"The fact they are involved does suggest that, rather than a perfunctory sign-off on some of the requirements that are present here in the United States system, these [surgeons] are truly involved in the cases," said the interventional cardiologist. "I think that that's a good thing to see."
In 2012, the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination that allowed coverage of TAVR under certain circumstances. Alongside stipulations related to hospital and physician volumes, it was also mandated that multidisciplinary heart teams, including cardiac surgeons and cardiologists, be actively involved in all aspects of patient care.
To check in on the issue, the STS explored how the heart team is used in practice by emailing an electronic survey to 2594 surgeon participants in the STS Adult Cardiac Surgery Database in June 2016. They received a total of 487 completed responses, giving a response rate of 18.8%.
Of the respondents, 410 (84.2%) reported that TAVR is performed at their institution, with 58.0% administered jointly by cardiology and cardiac surgery departments and 15.3% administered solely by the cardiac surgery department.
Referrals for TAVR came from both cardiologists and cardiac surgeons at 83.7% of institutions. Regular multidisciplinary meetings to discuss patients were scheduled in 91.4% of programs. As the report describes, these were weekly in 79.4% of TAVR programs, with 82.1% reporting that cardiac surgeons personally took part in the meetings.
Among 308 cardiothoracic surgeons who responded to a question on their involvement in TAVR, 89.0% said they were responsible for finding alternative access routes, whereas more than half said they took part in 10 of 11 intraoperative tasks detailed in the survey. They mostly took part in obtaining femoral access or alternative access, inserting the delivery sheath, positioning and deploying the valve, and repairing the femoral-access site.
The survey also revealed that 86.6% of respondents took part in postoperative care. Indeed, patients resided in the cardiac surgery service in 39.5% of cases and in a combined cardiac surgery and cardiology service in a further 34.0%.
The TAVR caseload ranged from zero to 20 cases a month, with five to nine procedures per month the most common, for 40.5% of cardiac surgeons. In addition, 36.0% of respondents performed zero to four cases per month, whereas the remainder performed 10 or more cases.
The team writes that the heart model "works and works well" for TAVR, adding that the multidisciplinary approach "systematizes and optimizes the entire process of patient care. Through shared decision making and joint procedural execution, all members of the team can bring to the patient their experience and expertise," they add.
"As a result, the right procedure can be performed on the right patient by the right doctor(s) at the right time and in the right way, thereby maximizing the likelihood of success while helping to ensure patient safety."
Kirtane agrees that the heart-team approach has worked. "Certainly, speaking from my own institution, as well as other institutions that have this model, it works smoothly," he said when interviewed. "It's the model that we should try to emulate, not only in the TAVR space but in other fields of cardiovascular medicine as well."
He questioned, however, the current CMS requirement that two cardiac surgeons assess patients before TAVR, especially given the success of the current heart-team approach.
It has been argued "that perhaps it ought to be a requirement for an interventional cardiologist who performs TAVR to see a patient prior to them going forward with a surgical aortic-valve replacement, given the preponderance of data supporting TAVR as a whole," he said. However, "these are minor points."
None of the authors had disclosures. Kirtane reports that his institution has received research grants from a variety of sources, including Medtronic, Boston Scientific, and Edwards.
Heartwire from Medscape © 2017 Medscape, LLC
Cite this: TAVR Team Effort With Cardiologists Predominates: STS Survey - Medscape - Apr 14, 2017.
Comments