Listen in as speakers Dr. Binak Shah and Dr. Karen Gersch give a post-lecture interview with Dr. Vinod Thourani. Drs. Shah and Gersch share their thoughts on how the field of both interventional cardiology and cardiothoracic surgery is changing and the collaboration needed between the two fields to decide which patients are better fits for transcatheter valve vs. Surgical valve replacement or repair.
Hello, I'm Vino. Thi, the Chief of Cardios Surgery at Piedmont Heart Institute in Atlanta, Georgia. And it's my pleasure to be here here at the 2023 Georgia Heart Institute conference at Chateau. I have two phenomenal people that we're going to discuss the topic of lifetime management of aortic stenosis. You guys want to introduce yourself. Yes, I'm Shaw. I'm the director of the cat lab and section chief of interventional cardiology at Brigham Women's Hospital in Boston. I'm Karen Gersh and I'm here in Georgia. I'm at the Georgia Heart Institute at Northeast Georgia Health System. I'm a cardiothoracic surgeon and I specialize in more minimally based approaches, but definitely I'm also participating transcatheter valves. Great. So let's talk about uh the the field you and I have been doing tas for a long time now. And um, and also surgical on my end and same with Karen, the field has moved, they're going to be in 2022. There are 97,000 taverns done in the United States, which is almost double what it is for isolated surgical valve therapies. Who do you now look at and say I'm going to send for surgery and of course, there's new data coming up. Maybe we'll wait for, wait to talk about that in a minute. But what patients do you believe are the ones that really should have surgery at this point? Talk to us about age a little bit also. So, uh, I do think about patients in terms of their age stratification. So we'll occasionally see the patients in their forties and early fifties with bad bicu valves. I mean, those patients are clearly going to get surgery and I think a big discussion is whether or not we should be thinking about a Ross procedure in those patients or a mechanical valve for sure. Um And then patients as we get more into our fifties and early sixties, I'm still generally leaning more towards surgery in those folks. And of course, the big discussion there with a lot of them is the mechanical versus the bioprosthetic valve. And a lot of these patients don't want to be on warfarin long term. Uh But um I think for a lot of them, it's really their best uh best solution and, and if they really don't want it, then we'll think about a, a bioprosthetic valve. Um So your, your bifurcation, if they're in their 56 6 want a mechanical valve, they'll go to surgery. If they want a tissue valve for a variety of reasons. Right, then you'll consider ta I will consider it, but II, I won't necessarily walk into the room thinking that tab is my first option. And if a patient sort of comes to me agnostic about what they want, then I'll probably lean more towards surgery that first time around. Only because I know that now surgeons are thinking much more about how to prepare that patient for tabs for the rest of their life if they really want a Tabb. Uh then, then that's where a very thorough anatomical assessment is, is important if they have, if they're going to get a nice large Taber valve with big sciences, high coronary and I feel confident that I could do another tab down the line. I'll say, ok, we can do this, but there are going to be some unknowns. I mean, we talked a little bit about durability this morning. Personally, I think that durability is not going to be a major difference between surgical and transcatheter valves. But we don't really have that bread of data yet. So I tell patients you're taking a little bit of a leap of faith, except that this valve is going to last as long as a surgical valve. So Karen, let me ask you to come in a little bit of a 56 year olds. Are you talking them into mechanicals or ross or, or tissue valves? How do you kind of figure all of that part out? It really is very much focused on that patient because we, there's, there's a whole variety of folks who are 50 60. Um I have many patients who come in with an agenda of, I don't ever want to have another surgery. Never have another procedure. They are very reliable folks and I feel comfortable proceeding with a mechanical valve and I have really have no qualms about mechanical valves. Now, the other folks who come in with a set in mind for Tabar, we really have to look at them much like you were saying, or there are other concomitant variables, coronary disease, aortic issues and then just really sit down and have a conversation with the patient or their annuus. How big is their annuus? Because then I can explain, we can do a root enlargement and get them prepare for a surgery, a trans valve down the road if we can get a nice big valve. But again, it's transparency of the conversation of. There's not one set way of doing this. So I think it's important what you're saying when you send the surgeons, how important is it for you to send it to the surgeon that's not going to put a 21 valve in? Right? So you're sending a 50 year old and they go to surgery and they get a 21 valve. How important, what conversations or what messaging do you have to surgeons for this? Yeah. So that's where it's, I think really important to be working with surgeons in a collaborative environment in a heart team model where they are. And I've said this to you many times, but I like to work with a surgeon who thinks like an interventional cardiologist. And I like to consider myself an interventional cardiologist who thinks like a surgeon. So it really has to be on their radar about what happens 10, 15 years down the line and they have to be willing to go the extra mile, do that route, enlargement and get as big of a valve in there. We are doing, we're doing no favors to any patients, really any patient putting in a 19 millimeter valve and most 21 millimeter valve. It's amazing to me how many nineteens and 20 ones I end up re operating on or, you know, they're so high risk. We have to do, you know, a tab on them as a bailout. But it, it's amazing. So a lot of messaging to surgeons and I tell surgeons that I'm on the bandwagon, please get ac t if you don't have ac T A patient, get one because some of the young surgeons don't know how to do. I don't even like root enlargement. I personally like annular enlargements that gives you much bigger um uh valve size implants. So, and some surgeons don't feel comfortable doing an annual enlargement. So they should have ac T done. So maybe they have their senior partner scrub with them, right? And so those are just do a root replacement. So those are things that are important. Would you, would you say the same thing? Uh on, no, but on a, a patient who is gonna get a 20 or 23 you know, uh Tara, would you say the same thing? Because if you're 60 you get a 20 or 23 million meter valve that becomes problematic too. So, what are your thoughts about that? Again? We have really dive in deeper discussions with our cardiology colleagues and make certain that we have a good plan, we have the appropriate imaging. And if we have a smaller Tabar valve and a young person, it's just not the right thing. I think all of us would agree. There's a failure across the board and then both of us having the conversation with, with our patients saying this is just not the right thing. And here are the reasons why. So where do you stand? Especially these younger patients, low risk patients, by the way, constitute about 34% of all vers of the United States. So last year, 34,000 low risk patients got received a ver do you put these patients on and tell us your anti coagulation strategy from the surgery side car, you'll go next and on the side. Uh Benny, tell us what you do. That's it's a good thought and I still don't think we have the final answer on the best way to manage these patients. But right now, we're still just doing single antipla therapy with aspirin. I must have some other reason to be on Warfarin. We're doing the same thing and be, I'm not sure it's the right thing because I think Thrombus early on which we see it in tavern and surgery does lead to early SVD structural valve deterioration. What do you do on the, on the surgical side? So, um I have was always trained to use cumin or some type of uh uh blood thinning of that sort. Now, the trend has gone back to just aspirin on the surgical valves. Now for transcatheter valves, I think there is a question, what do we do? Do we anti coagulate this for P three right now. I don't think there's enough data for the two year trial review to say that we need to anti coagulate people. But I suspect that might be something that we need to do across the board for these folks moving forward, particularly in folks who are low risk. I think it fell out of favor for us anti coagulating folks traditionally because they were 80. But now that we're looking at a younger population, I think there may be an advantage to anti coagulation. So we have uh in October at TCT most likely the uh we have the results of the five year part of three study comparing surgery and tar and low risk patients, but average age is still 72 73. What do you think? What if surgery if the mortality differences are not different between the two. Do you think that's a win for tavern? Do we just move that field forward? How we answer the question or? What's your thought? What's your thoughts? What are we going to see? And how are you going to take that? Well, you know, you showed very nice data this morning. The curves have come a little bit closer to each other in terms of mortality. And so my sense is that five years, I think that we'll probably see that the curves are very similar. I think the mortality will be very similar. And, and I do think that's a win for tar only because we are taking the invasiveness of surgery out of the, out of the mix. But I still don't think five years is long enough for these patients. Now again, in partner three, the average age was 74. Uh when we're talking about doing this in 60 65 year old patients, we really have to know what happens 10 to 15 years out. I agree, Karen, what are your thoughts about this as part of three is about to roll out in a couple of months. I think you stuck the landing on that one. I agree. I think we need a little bit more data, a little bit further out data to determine if these 50 60 year olds are better served with tar. But it's exciting to see this because I think there are several wins for transcatheter valves, but the data needs to go a little bit further out for me to tell my 50 some year olds that this is the best choice for them. Well, thanks to both of you for spending the last 10 minutes with us. And again, thank you for the Georgia Heart Institute for allowing us to do this interview on the lifetime management of aortic stenosis.
