BCPA Journal - Issue 184 - British Cardiac Patients Association

10
NICE guidance boost for patients needing TAVI
Dr Bernard Prendergast, Consultant Interventional Cardiologist,
John Radcliffe Hospital, Oxford
Good news for patients with aortic stenosis!
On 28th March 2012 the National Institute
for Health and Clinical Excellence (NICE)
provided updated positive guidance on
the use of Transcatheter Aortic Valve
Implantation (TAVI) for the treatment of
high risk patients with severe aortic stenosis
who are unsuitable for traditional open heart
surgery.
For interventional cardiologists like me,
who have been working on TAVI since
2007, it is welcome recognition of the fact
that the procedure is now viewed as an
established alternative to surgical aortic
valve replacement in the most seriously ill
patients.
Technology
With TAVI, we are able to implant a new
aortic valve within the diseased valve
using keyhole techniques – either via the
leg artery (transfemoral) or a small chest
incision through the ribs (transapical). This
technology provides a treatment option for
those who are too ill for open-heart surgery
or have anatomical reasons why their aortic
valve cannot be replaced using traditional
techniques.
Our experience with TAVI in the UK
has been very positive to date, although
expansion of the technique has been
limited – of more than 40,000 procedures
undertaken worldwide, only 1,500 have
been performed in the UK. Nevertheless,
our results compare favourably with
those of our international colleagues and
further expansion seems likely as a result
of falling costs, encouraging clinical
evidence, recommendations of international
guidelines, and the recent guidance from
NICE. Consequently, many more deserving
patients with aortic stenosis will benefit
from what TAVI can offer.
The PARTNER B Trial from the US
certainly provides outstanding data to
support the clinical enthusiasm for TAVI.
In this study, mortality at one year was
20% lower in patients treated with TAVI
than those treated with standard therapy of
medication with or without a simple balloon
stretch procedure (balloon valvuloplasty). 1
In other words, only 5 patients required
treatment with TAVI to save 1 life.
Furthermore, the trial also showed rapid
recovery and convalescence after TAVI,
encouraging improvement in day-to-day
symptoms (breathlessness, chest pain and
dizziness) and overall measures of Quality
of Life, and reduced need for repeated
hospital admission in virtually all subjects. 2
These outcomes match the experiences of
clinicians involved in the management of
this challenging group of patients.
Specialist assessment essential
TAVI cannot, of course, help absolutely
everyone. Some patients may be simply
too ill or frail to gain from the procedure
and in others there may anatomical issues
which make valve implantation impossible.
The role of the specialists is to assess each
patient carefully to determine whether their
condition is most suitable for conventional
surgery, TAVI, balloon valvuloplasty,
or conservative medical therapy. This
decision is best made by multi-disciplinary
teams (MDTs) consisting of surgeons,
interventional cardiologists, anaesthetists,
imaging specialists, and physicians with
experience in the care of the elderly, all of
whom who have been specially trained in
the procedure. These teams must be based
at certified centres that have full access to
the specialised equipment and resources
necessary to perform TAVI.
An inevitable question is whether TAVI
could eventually replace conventional
surgical valve replacement, in the same way
that keyhole procedures for gallstones have
superseded open abdominal surgery. At this
stage, it is too early to form a conclusion
since long-term results are not yet available
and superiority over surgery is yet to be
demonstrated. The TAVI procedure and
associated technology is evolving rapidly
and it seems likely that more and more
patients will be treated using the technique
in years to come. However, we should
remember that it remains a major invasive
and high-risk procedure that is still in its
development phase. Moreover, conventional
surgical aortic valve replacement is a
tried and trusted procedure with excellent
immediate and long term results in well
selected patients. TAVI should not be
offered to patients simply out of preference
for a less invasive approach.
Most exciting developments
Without doubt, TAVI is a ground breaking
alternative to open heart surgery and a
potential saviour for certain patients for
whom surgery is not an option. It is one
of the most exciting developments in
cardiology that I have seen in my career and
I am certain the procedure has a positive
future.
Sources 1 Leon MB, Smith CR, Mack M,
Miller DC, et al. Transcatheter Aortic-
Valve Implantation for Aortic Stenosis in
Patients Who Cannot Undergo Surgery N
Engl J Med 2010; 363:1597-1607
2 Reynolds MR, Magnuson EA et al.
Health-Related Quality of Life After
Transcatheter Aortic Valve Replacement
in Inoperable Patients With Severe Aortic
Stenosis. Circulation 2011;124:1964-197
Talks offered – Alan Thomas, BCPA Life member
A professional speaker for many organisations, I am happy
to offer talks without fee to any BCPA Area Group, but
would require travel expenses if the venue lies outside
the Greater London area. Perhaps there may be another
charity that you, a reader, are a member of, eg WI, U3A or
some other who may be interested in one of the list I offer.
The talks I have available are:
• New York – impressions and experiences from many
years of living there; and/or the discovery, development,
scope and character of New York city
• Public speaking – pleasures and pitfalls
• The lively mind – approaches and techniques for
keeping an active mind
Statue of Liberty,
New York
The TAVI valve
is crimped to a
pencil thin size
before entering the
femoral artery. It is
then implanted into
the aortic valve by
balloon-inflation.
The SAPIEN XT
valve is one of the
TAVI valves available
to interventional
cardiologists and
cardiac surgeons.
• Our reminiscences – their value, reliability, prompting
and recording
• Stories – their multiple uses, including performances of
stories of contrasting types
• The Statue of Liberty – precursors, European
inspirations, engineering features, Emma Lazarus, the
ever-changing meanings of the symbol, and immigration
• Carnegie Hall – origins, development, functions, and
how saved for posterity
Please contact me at 0208 579 6606, alro.th@virgin.net,
or 16 Park Place, London W5 5NQ.