Spotlight on TAVR: Interview with Vinod Thourani, MD, Advisory Board Member

Vinod Thourani, MD, of Emory University, offers his insight into various TAVR clinical practices.

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 ( 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.