Feature | October 02, 2013| Brijeshwar Maini M.D., FACC, PinnacleHealth, Harrisburg, Penn.

TAVR — Ushering in a New Era of Cardiovascular Disease Treatment

Advice on how to build a robust TAVR program to improve patient outcomes while lowering cost

Sapien, TAVR, hybrid OR

TAVR procedures require clear imaging of the aortic valve for both sizing and the procedural guidance. CT is used for sizing and planning procedures, and angiography and TEE are used to guide the procedure. Pictured is a Sapien valve implantation by Mayo Clinic.

medtronic Corevalve, TAVR

The Medtronic CoreValve transcatheter aortic valve is currently in U.S. pivotal trials. It already has CE mark in Europe.

Edwards Sapien TAVR valve

The Edwards Sapien is the only FDA-cleared transcatheter aortic valve currently on the U.S. market.

Imagine being a patient with a curable disease, but no treatment option. That was the reality for many ill patients suffering from aortic valve stenosis who were not eligible for open-heart surgery. However, with the introduction of transcatheter aortic-valve replacement (TAVR) a treatment now exists.
After several years of trials and increased clinical use, TAVR has reached a tipping point for becoming the standard of care. It is successfully allowing patients to live longer with a better quality of life and is costing hospitals less money. 
As a cutting-edge technique, many hospitals around the country are investigating the development of their own TAVR programs. Starting a TAVR program requires a collaborative commitment to care and advanced imaging technology to plan and perform the exams. With the right approach and equipment, a TAVR program can have a profound impact on patients and the hospitals that serve them. 
A Collaborative Approach to Building a TAVR Program
At the inception of medicine, one general physician served all the needs of their patients, regardless of the specific symptoms or ailment. Over time, that evolved into today’s system where physicians focus on specific organs or areas of the human body. This often results in a siloed approach to problem solving and treatment. These philosophies are now intersecting, and clinicians with different specialties and expertise are working together for more efficient, holistic approaches to patient care.
Implementing a successful TAVR program requires a multidisciplinary, collaborative commitment. The knowledge base of cardiologists and interventionalists must be aligned with the expertise of surgeons for the procedures to be successful. From the onset of TAVR program development, there must be buy-in from all of these disciplines. 
At PinnacleHealth we have developed a “heart-team” approach for our cardiac patients. Working collaboratively literally brings the best experience to the surgical table. 
In 2004, when TAVR was in its infancy, we developed the relationship between the surgical and percutaneous expertise of our clinicians. We gained practical experience by being a part of almost every structural heart trial going on in the country. 
As our familiarity with each other grew, our volumes increased and the results improved. This collaboration enables us to continue pushing the envelope and explore innovative ways to improve patient outcomes with more efficiency. This matters to the patient, to insurers and to our practice overall.
The Economic Upside of TAVR
The goal of healthcare is to provide patients with superior care that is as economical as possible. In the treatment of heart failure, reducing readmissions ensures treatment is done correctly the first time, helping to lower overall costs. There is often a misconception that newer procedures are more expensive and result in a greater burden for the healthcare system. For TAVR programs, the opposite is true, as it can help reduce readmissions of heart failure patients, who are the sickest and most vulnerable for long medical stays.
In the United States, the majority of the money spent on healthcare is in the last few days of a patient’s life. By treating patients who were previously unable to undergo surgery, TAVR is able to improve the lives of patients and reduce the amount of medical attention necessary.
For hospitals that are able to push the envelope with cutting-edge treatments like TAVR, the economic benefits are tangible, and when done right, can be quantified. Sick patients will seek out facilities offering the latest procedures and best technology, and these hospitals will be able to attract more patients and increase referrals. 
The Right Technology 
Diagnostic imaging technology plays a crucial role in TAVR and now offers interventionalists the operational vision that only surgeons used to have. From planning to execution, new technologies are constantly improving the quality of care and making TAVR procedures easier to perform. 
The most important decision for TAVR is developing the right lab. A hybrid operating room (OR) is a must, as these procedures are not successfully completed in a traditional cath lab. The versatility of the hybrid lab allows clinicians to respond to any situation that may occur during the procedure. The larger size of hybrid rooms also provides enough space for the clinical staff and additional equipment needed during these procedures. 
When planning new labs, it is critical to have a vision and build for the future. At PinnacleHealth, we developed our hybrid OR lab eight years ago, before TAVR procedures began. Our foresight in creating a large hybrid lab with the right imaging technology enabled us to implement TAVR when we were ready. 
The centerpiece of a hybrid OR is the angiographic X-ray imaging system used to guide procedures. We selected Toshiba’s Infinix-i cardiovascular X-ray system, which gave us the versatility we needed for innovations in procedures and the low-dose technology for longer exams. The system offers unrestricted patient access, flexible C-arm movement and high-resolution images, enabling our physicians to conduct advanced TAVR procedures with maximum efficiency. 
The system’s flexible design streamlines procedures, allowing us to obtain a wide range of imaging angles without repositioning the patient. The X-ray system combined with the OR table produces a hybrid lab that is ready for today’s exams and tomorrow’s innovations.
Computed tomography (CT) and ultrasound also play an important role in planning for TAVR and helping to determine if a new valve is appropriate and what size. 
The growth in TAVR procedures is bringing less invasive, more efficient and lower cost treatments to patients. It is one of the biggest recent breakthroughs in cardiovascular care. TAVR will continue to grow, and the patient sets eligible to be treated will expand, replacing open surgical procedures with less invasive interventional exams. 
The healthcare industry can learn a lot from this example. Combining long-term strategy and collaborative planning with innovative, flexible technology, can make a positive impact on patient care while improving the bottom line.
Editor’s note: Brijeshwar Maini, M.D., FACC, is the director of advanced cardiac and endovascular interventional laboratory, director of cardiovascular research and education, and medical director of the PHCVI valve clinic at PinnacleHealth, Harrisburg, Penn. He is a pioneer in TAVR procedures, having performed them since 2004.

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