Study Urges Individual Patient Assessment of Benefits and Futility of TAVR
In the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a leading alternative to invasive surgery treating patients with severe symptomatic aortic stenosis. However, as with any technology, there is still a need for physicians to identify and acknowledge its futility in individual patients.
A study published June 18 in JACC: Cardiovascular Interventions reviews the issues that need to be considered when making and communicating the decision of a TAVR procedure, and emphasizes the need for a multidisciplinary heart valve team to discern "who will benefit from the procedure, who will not, and those in the gray zone where the most patient engagement is needed."
The study, led by Brian Lindman, MD, MSCI, Washington University School of Medicine, St. Louis, MO, noted that physicians looking at TAVR as a treatment option must first perform a clinical risk stratification, looking at factors such as a very high Society of Thoracic Surgeons score, impaired LV systolic function, low valve gradients, a reduced stroke volume index, and severe myocardial fibrosis, as well as severe concomitant valve disease, severe pulmonary hypertension, and severe lung, renal and/or liver disease. In addition to these traditional comorbidities, age-associated conditions such as frailty, disability, mobility impairment, cognitive impairment, mood disturbance, malnutrition, polypharmacy, fall risk, and even social isolation must be taken into account.
Once these risks are properly taken into consideration, the authors advocate that estimations must be made towards the procedure's ultimate functional benefit and symptomatic improvement. Just as important, assessments must be made in regards to the patient's goals and preferences, reaching a consensus on the risks and what they could influence one's quality of life versus quantity of life.
Given the diversity and breadth of these issues to consider when evaluating candidates for TAVR, Lindman et al. stress the importance of a multidisciplinary heart valve team to provide additional insight and expertise to make the best decision regarding who is most likely to benefit from the procedure. Recommended staff to this team should include cardiac surgeons, interventional cardiologists, and noninvasive cardiologists, each with a particular expertise in complicated structural/valvular heart disease. If and when such a group determines that TAVR would be futile, Lindman and his co-authors feel that it is imperative to ensure the continued access of clinical care for the patient.
"TAVR is an immensely promising therapeutic intervention, but as we work on technological innovations to improve the procedure, we must also use it responsibly and safely within a framework of care that enables shared decision making and promotes patient goals and well-being," noted Patrick T. O'Gara, MD, FACC, president of the ACC and a co-author of the article. "In addition, the STS/ACC TVT Registry continues to be a resource to track patient safety and real-world TAVR outcomes."
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