While attending the 2016 American Heart Association Scientific Sessions in New Orleans, Cardiology Advisor had a chance to chat with editorial advisory board member Vinod Thourani, MD, of Emory University in Atlanta, Georgia.
Dr Thourani is a cardiothoracic surgeon who specializes in transcatheter aortic valve replacement (TAVR), as well as an investigator in several of the PARTNER clinical trials (ClinicalTrials.gov identifiers: NCT00530894, NCT01314313, NCT02184442, NCT02687035, and NCT02675114) . He offered his insight into various interventional practices.
Cardiology Advisor: Why would one choose to perform percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR)?
Dr Thourani: It depends on the significance of the lesion. If a patient is older and/or has an insignificant lesion, the tendency is to not perform PCI. We’re letting some of the disease go. We can also use FFR [fractional flow reserve], say for the LAD [left anterior descending artery], to detect whether or not there’s actually a problem. Then, typically, we’ll wait 1 month for healing before performing TAVR.
It is rare for us to go back after TAVR and perform a PCI. Of the 1600 cases at Emory, we’ve had fewer than 5 incidents of concomitant PCI/TAVR. It’s unbelievably rare—less than 1%.
Cardiology Advisor: Would you say this is indicative of what’s happening all across cardiology, not just interventional?
Dr Thourani: Yes, definitely. We’re seeing it in a lot of PCI trials. We’re really only intervening if the patient is symptomatic.
Cardiology Advisor: Let’s talk about cerebral embolic protection in TAVR.
Dr Thourani: We have seen a large reduction in stroke because of the device. There is a difference in balloon vs self-expanding valves, though. I think subgroup analyses will be important in determining which patients need it the most—having previous stroke or high calcium volume, for example.
We’ve had less than 2% of strokes at Emory without neurological adjudication. The national average is somewhere around 2.2%, so I suspect once we’ve been evaluated, we’ll be around 1.5% to 2%. It is the deadliest complication in TAVR so we do need to be mindful of it.
Cardiology Advisor: How difficult is it to integrate transcatheter cerebral embolic protection into the TAVR procedure?
Dr Throuani: Well, yes, it is a lot [in the operating room]. And as the recent SENTINEL clinical trial showed, there was debris in nearly 99% of the devices after, which means we need to check on them for “silent events” because that could lead to dementia. This also occurs in surgical [aortic valve replacement], too.
Cardiology Advisor: You weren’t surprised by the recent long-term durability and QOL outcomes with the SAPIEN device, were you?
Dr Thourani: No, not surprised at these good outcomes. [At Emory], we’ve had fewer than 5 patients come back for structural valve deterioration.