Transesophageal echo (TEE) being used to guide the deployment of a MitraClip device during a transcatheter structural heart procedure in the hybrid lab at the University of Colorado Hospital. The center has performed more than 200 MitraClip mitral valve repairs over the past decade. Photo by Dave Fornell
As a medical technology journalist, a little more than a decade ago I found myself sitting in those late afternoon "future technology" sessions at the Transcatheter Cardiovascular Therapeutics (TCT) conferences. The sessions sometimes had a sea of open chairs as cardiologist attendees peeled off to get dinner or enjoy visiting the host city after long day. This is where I was introduced to transcatheter valves and the promise the technology might have in the years to come to possibly change how cardiology is practiced.
The development of transcatheter aortic valve replacement (TAVR) at the time was more of a cool science fiction project, and I thought this would be something awesome if it could be made to work, showed good enough outcomes and the procedure made easy enough for most experienced operators to master.
But you could sense the questions and serious doubts in the few people who were in the audience. I remember overhearing some attendees question if it would ever work or if the durability would ever come remotely close to open heart surgical valve replacement.
A decade later, TAVR not only proved itself better than surgery, but can be performed as an outpatient procedure, or with just an overnight stay at the hospital. It is also a no-brainer for patients as to which procedure they would prefer, if they qualify for TAVR under the appropriate patient selection criteria.
I remember when new stent technology and stent late-breakers were what TCT revolved around. But the last few years, TAVR and the now broader category of structural heart interventions are among the biggest drivers of excitement and crowds at TCT.
That excitement a few years ago translated quickly from awesome clinical data in the late-breaking trials to packed, standing-room-only crowds in sessions about mitral valve and other transcatheter technologies in development. There are no longer future technology sessions on transcatheter valves that are a sea of empty chairs. Some of these session have moved to prime time slots and were packed solid, at least the last time I could be there in person before COVID in 2019.
So today, as TAVR now makes up more procedural volume in the U.S. than surgical aortic replacements, many hospitals that have not already created a structural heart program are now looking at creating one. And not just because TAVR is going so well, but because its success has led to the expectation that the same will happen with mitral and tricuspid valve repair and replacements, and additional procedure volume opportunities with left atrial appendage occlusions, ASD and PFO closures and a number of other structural heart interventions that are being investigated. With the success of TAVR, even some of the craziest ideas for transcatheter intervention now get a second look and are not considered as crazy as they might have been 15 years ago.
That said, there is a strong current in the sea of cardiology that has shifted direction in how cardiologists treat structural heart patients. For centers that have had strong cardiovascular surgical programs, I have interviewed a few cardiology luminaries who feel those centers may need to reevaluate how their programs will look in 10 years based on the transcatheter trends.
Now is the time to start looking at creating structural heart programs to bring together interventional cardiologists and surgeons as part of a large care team to decide what is best for each patient. For many centers, this means some patients do not qualify for TAVR due to anatomic issues and may be best suited for surgery. For those who do get a TAVR or other transcatheter procedure, these often involve the cardiac surgeon. It is a way to adapt to the market trends, be innovative in the eyes of the community they serve and enable surgical referrals even from patients seeking a transcatheter procedure.
A few years ago there were questions if transcatheter structural heart programs could gain enough volume to be successful. A few years later, I feel the question is will there be enough procedure volume to keep the doors open if a hospital only has a surgical program that is not a part of a structural heart program. It makes good business sense, and I see all signs that this will be the way of the future as surgical volumes steadily decrease in the coming years, yielding volume to transcatheter devices.
Here are some links to articles and interviews where you can hear thoughts from some of the structural heart experts:
VIDEO: Overview of the Structural Heart Program at Tufts Medical Center — Interview with Charles D. Resor, M.D.
Hospital Consolidation May Increase Access to TAVR, New Cardiac Technologies — Northwestern Medicine experience
VIDEO: Advice For Hospitals Starting a Structural Heart Program — Interview with John Carroll, M.D.
VIDEO: Overview of the Henry Ford Hospital Structural Heart Program — Interview with William O’Neill, M.D.
VIDEO: Transcatheter Mitral Valve Replacement Planning — Interview with Joao Cavalcante, M.D.
VIDEO: How to Build An Integrated Heart Team — Interview with Brijeshwar Maini, M.D., and Brian Bethea, M.D.
VIDEO: Overview of the TAVR Program at Tufts Medical Center — Interview with Andrew Weintraub, M.D.
VIDEO: Transcatheter Mitral Valve Interventions at Henry Ford Hospital — Interview with Marvin Eng, M.D. and William O’Neill, M.D.
VIDEO: Applications in Cardiology for 3-D Printing and Computer Aided Design — Interview with Dee Dee Wang, M.D.
VIDEO: What to Look for in CT Structural Heart Planning Software — Interview with Jonathan Leipsic, M.D.
VIDEO: The Essentials of CT Transcatheter Valve Imaging — Interview with Jonathan Leipsic, M.D.