Invited Commentary

Abstract

The report by Bavaria and coauthors [1Bavaria J.E. Prager R.L. Naunheim K.S. et al.Surgeon involvement in transcatheter aortic valve replacement in the United States: a 2016 Society of Thoracic Surgeons survey.Ann Thorac Surg. 2017; 104: 1088-1094Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] provides a broad overview of the involvement of surgeons in transcatheter aortic valve programs. The results confirm their frequent participation in all aspects of care, including the referral and evaluation process, the procedure itself, and postprocedure care. The spectrum of procedural involvement by surgeons is framed between the extremes of the surgeon as the primary transcatheter aortic valve replacement (TAVR) proceduralist and the surgeon who stands in the control room watching. The original pivotal TAVR trials established the team approach and the subsequent decision by the Centers for Medicare and Medicaid Services for coverage of TAVR solidified the team, but individual variation of involvement will continue as some surgeons pursue the full breadth of interventional skills and others confine their involvement to a subset of the steps performed during TAVR or to those cases requiring a hybrid approach. Traditional surgical skills are, and will, remain essential to transcatheter valve therapies. Currently approximately 93% of TAVRs being entered into The Society for Thoracic Surgeons-American College of Cardiology Transcatheter Valve Replacement Registry (ATS/ACC TVC Registry) are performed through transfemoral access and rarely by access through a cutdown procedure. This stands in contrast to the first few years of TAVR in the United States when alternative access was 40% to 50% and femoral cutdowns were often used. This shift has reduced, but certainly not eliminated, the need for surgical skills. Likewise the need for mechanical support and conversion to an open surgical procedure have diminished but not disappeared. Fundamental to the team approach to TAVR is the presence of team members with skills and experience who can plan and execute TAVR in those patients needing alternative access or transient mechanical support. In addition, effectively responding to sudden events such as annular rupture, coronary occlusion, and iliac dissection will require a team response even if the site restricts their activity to “simple femoral cases.” The Society of Thoracic Surgeons survey does not identify some of the nuances of evolution in the team approach and surgical career model. Young cardiac surgeons have a decision to make—“How deeply do I go into the interventional skill set and how do I develop these skills when few of my senior mentors have them?” With increasing volume at a TAVR center in which surgeons and interventional cardiologists are fully engaged, the playing field has leveled between the specialties in the critical aspect of intraprocedural troubleshooting and decision-making. Surgeons have the experience to recognize evolving complications, make technical suggestions, and become facile with performing catheter and wire tasks. Finally the emerging transcatheter mitral space will be facilitated by the established culture of the surgical-interventional partnership. Being at the table is the key for all operators to become competent and able to contribute and to become wise to lead the next decade of innovation and major care transformation in cardiac transcatheter therapies. Surgeon Involvement in Transcatheter Aortic Valve Replacement in the United States: A 2016 Society of Thoracic Surgeons SurveyThe Annals of Thoracic SurgeryVol. 104Issue 3PreviewThe Society of Thoracic Surgeons (STS) surveyed cardiothoracic surgeon participants in its Adult Cardiac Surgery Database (ACSD) to learn the extent of surgeon involvement in transcatheter aortic valve replacement (TAVR) procedures. Full-Text PDF