Heart team should decide if TAVI is suitable for low-risk patients

At the EuroPCR 2016 Great Debate (17 May), three cardiac surgeons and three interventional cardiologists met head-to-head to discuss whether transcatheter aortic valve implantation (TAVI) should be extended to low-risk patients. The panel agreed that, in current practice, a heart team should decide whether using TAVI or conventional surgery was the best approach. According to the panel, the heart team should base their opinion on specific patient clinical data. There was also a call for more data especially regarding durability of the bioprosthetic valves.

The team of panelists comprised cardiac surgeons Jean Francois Obadia, Gerhard Wimmer Greinecker and Thomas Walter, and interventional cardiologists Darren Mylotte, Lars Sondergaard and Stephan Windecker.

The cardiac surgeons raised concerns about durability of TAVI devices. J.F. Obadia told delegates that his main issue of concern was the post-TAVI long-term follow-up, especially for young patients, as “we have absolutely no evidence that those valves will last for several years.”

G.W. Greinecker commented that even though he is an “absolute supporter” of TAVI, at this point, “it is time to step a little bit on the brakes”. Therefore, there should be caution about using the procedure in lower-risk patients.

T. Walter said that at present treating low-risk patients with conventional surgery has shown “perfect outcomes” but he mentioned that there are still several aspects to consider when treating low-risk patients with TAVI. For example, very difficult valve morphology with extensive calcification, he said, and added: “I do not believe that TAVI is the best option for longevity”.    

D. Mylotte mentioned that echocardiographic data from randomised trials comparing TAVI with surgery indicate at least comparable if not superior haemodynamic performance of transcatheter heart valves compared with surgical valves throughout five years. Regarding available TAVI data for the low-risk patient population, L. Sondergaard (principal investigator for the NOTION 1 and NOTION 2 trials, which are comparing TAVI and surgical aortic valve replacement in younger low-risk patients) said that these trials have shown evidence that TAVI is safe and efficient in low-risk patients. He also made the point that in order to define whether TAVI is appropriate for low-risk populations, it is needed to look at younger populations (patients between 60 and 65 years) as this has not been explored in the previous trials.

S. Windecker supported L. Sondergaard’s position, and commented: “We have witnessed that TAVI has matured in a very secure and reproducible technique and we have a sound body of evidence that truly justifies that this intervention can be extended to low-risk patients.” He also mentioned that data from randomised clinical trials performed to date indicate a survival benefit of TAVI over conventional surgery at two years of follow-up.

However, the panel also questioned whether a younger age necessarily meant longer life expectancy, as it was noted that a younger patient may have several comorbidities and therefore “be sicker”. 

EuroPCR advisor Alec Vahanian summarised the take-home message of the debate by saying that in the current practice the heart team is important deciding which patients to treat with TAVI. “The classification of low risk, intermediate risk, high risk or surgery is not a good way to select the patient. It is old-fashioned. We should really look at the whole picture of the patient, and the heart team is in charge of making the final decision,” he noted.

He also commented that there is a need for more data for TAVI in low-risk patients, especially regarding durability of devices.

Alan Spencer moderated the session.

Heart team should decide if TAVI is suitable for low-risk patients