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The more robust the TAVI data become , the more patients will be treated with this technology it was still too early to increase the number of TAVI centres , especially as one of the requirements for a TAVI programme , and which is a recommendation in both the American and European guidelines , is the need for on-site surgery , although he is aware that some centres perform TAVI without on-site surgery .
Prof Van Mieghem believed that the level of complications from TAVI were dependent on both patient factors and the experience of the interventionalists carrying out the procedure . Nevertheless , he thinks that the complication rates are still far lower than for surgical procedures . A concern among cardiologists is the unknown durability of the TAVI valves , as he said , “ we simply don ’ t know how long these will last compared with surgical valves ”. While there is little reason to think that TAVI valves are inferior to surgically replaced valves , in the absence of definitive data , it could become more difficult to get cardiac surgeons to abandon their low-risk surgery patients for a TAVI . While comparative outcome data are available for both types of valves , he described how the study follow-up time has only been 5 years . An added and relevant complication is the patient-related risks . As he explained , “ these early trials relied on high-risk or inoperable patients , so that these patients had a 5-year mortality of 50 – 80 % and often died because of other problems rather than their valves ”.
He added that in more contemporary , comparative trials among low-risk patients , at least in the short-term , TAVI is associated with fewer complications . However , the use of TAVI has expanded , and he said that around 50 % of valve replacement procedures are now done as TAVI rather than surgery .
What have been the biggest challenges during the COVID pandemic ? The biggest challenge created by the pandemic was a lack of hospital beds . As COVID units expanded due to increasing case numbers , available beds on general wards reduced as wards were transformed into intensive care units . This change ultimately reduced the capacity for semi-elective procedures including TAVI . However , because the procedure at Erasmus did not require intensive care or anaesthetists , the overall impact was minimal . Prof Van Mieghem described how the department workload only “ decreased by about 10 %, although in other centres , the workload decreased by 50 % or more ”. Part of reason why his centre ’ s workload did not undergo a significant drop , he feels , is because they have a “ very streamlined TAVI programme ”.
A further contributing factor to the reduced workload was the closure of outpatient and general practitioner clinics , hence fewer patients were being referred for TAVI . A downside , however , was that the threshold for referral increased , in other words , only those with the most severe disease , for example , decompensated aortic stenosis , were being referred for TAVI .
Looking to the future , what innovations would you like to see ? He thinks that technological advances will definitely occur , and , in particular , that devices will become smaller , reducing access problems and bleeding complications . A further development is likely to be “ a better understanding of this issue of conduction disorders and the need for new pacemakers after TAVI ”, which is related to the radial strength of the technology and “ the extent to which it protrudes into the ventricle rather than sticking to the aorta ”. Finally , he hopes that TAVI will evolve to fully protect the brain of all patients . He described how during the TAVI process it was possible for some remnants of the old valve to embolise to the brain , creating neurological events .
Prof Van Mieghem believes that “ the more robust the TAVI data become , the more patients will become treated with this technology ”. An additional driving factor is the public ’ s increasing awareness of the procedure , as highlighted by the case of Rolling Stones ’ lead singer , Mick Jagger , aged 74 , who had a TAVI valve fitted after feeling increasingly tired during a tour 2 years ago . As Van Mieghem described , “ three months after his TAVI , Jagger was dancing and fooling around on stage and people came to the outpatient clinic with that story , asking for the valve that Mick Jagger received ”.
Final words To Prof Van Mieghem , TAVI is a procedure that would always be chosen by most patients when given a choice . As he deliberated , “ if you can get a procedure under local anaesthesia , that takes 45 minutes and up to 48 hours hospital admission time and then immediate recovery , versus treatment under general anaesthesia , with a sternotomy and a hospital time between 7 and 10 days and a recovery time of 3 – 6 months ”, then the decision is , he says , simply “ a no brainer ”.