The introduction of transcatheter aortic valve replacement (TAVR) transformed the treatment of aortic stenosis (AS), offering an important alternative for patients who were not appropriate candidates for surgical aortic valve replacement (SAVR) and eventually becoming a first-line option for many patients. But Isaac George, MD, a cardiothoracic surgeon and surgical director of the Structural Heart and Valve Center at NewYork-Presbyterian and Columbia, says the decision between TAVR and SAVR is not one-size-fits-all and should take into consideration a patient’s age and life expectancy, their anatomic features such as coronary height and aortic annulus size, and the durability of the valve.
In an expert review published in the Annals of Thoracic Surgery, Dr. George and his colleagues explore how to rank those considerations to minimize the risk for patients and propose an algorithm to guide the choice between SAVR and TAVR. Below, Dr. George explains why it’s important to think about the lifetime management of AS – not just a single procedure.
Severely stenotic aortic valve with extensive bulky leaflet calcium.
Individualized Approach
The proposed algorithm that we put together is an effort to bring the knowledge and experience of both surgeons and interventional cardiologists into one place. The algorithm mirrors the way that the multidisciplinary team at NewYork-Presbyterian and Columbia works to evaluate patients with AS and incorporates our accumulated experience performing TAVR. We have regular valve meetings that involve surgeons, interventional cardiologists, general cardiologists, radiologists, nurse practitioners, and physician assistants to review the device durability, age and life expectancy of the patient, anatomic factors, and surgical risk to determine the best first therapy, while also taking into account potential future interventions. The algorithm creates a decision map that starts with the patient’s life expectancy and moves through the anatomy and surgical risk to help guide the choice between TAVR and SAVR.
Lifetime Management
Before undergoing TAVR or SAVR, our patients undergo computed tomography angiography (CTA) and a multidisciplinary valve team evaluation to formulate a management strategy that is individualized and covers their expected lifetime. Sometimes our choice of a first procedure, or the way we do the procedure, can make a second or third procedure higher risk. In the long run, that may not be the best decision for the patient, so we need to consider all those risks at the beginning of the process. Part of the shared decision-making with patients is walking them through the risks over their lifetime and giving them a chance to decide what they value, whether that is extending life or limiting the risk of reoperation.
AI Tools
Fortunately, we have new tools -- imaging programs, virtual modeling, and artificial intelligence (AI) -- that can take our existing data sets and provide a quantitative measure of the patient’s risk for complications, with insights on the risk of rupture, coronary occlusion, potential thrombosis, and flow patterns. It can also model the outcomes for follow-up procedures. We use a commercial AI program that takes the patient’s CTA and maps out the surgical considerations, providing a patient specific analysis that we can use in discussions with patients. Now the patient can make a decision that is based not only on my clinical judgement and experience but with quantitative risk data that is individualized for them.
