“We now live in a world of wires,” commented Tom C Nguyen (chief of cardiac surgery, McGovern Medical School, University of Texas, Houston, USA) in his presentation during a late breaking abstract session at the 34th European Association for Cardiothoracic Surgery Annual Meeting (EACTS 2020, 8–10 October, virtual). During the presentation, Nguyen sounded a note of caution over what he describes as the “creep” of transcatheter technology into lower risk patients for whom there is currently little long-term follow-up data.
Despite this warning, Nguyen said that surgeons should embrace the advent of transcatheter technology, and he called for further collaboration between specialists in interventional cardiology and cardiothoracic surgery, as well as further research to determine the best treatment options for individual patients. “It should not be surgeon versus cardiologist, it should be surgeons and cardiologists doing what is best for patients,” he said.
In his presentation, Nguyen pointed to data which demonstrated an increase in the number of transcatheter aortic valve implantation (TAVI) procedures, or use of the Mitraclip (Abbott) device for the treatment of mitral regurgitation, in low and intermediate risk patients, who may be suitable for surgery. He said: “We need to remember that the longest randomised follow-up we have so far is five years, [and] there is only one randomised controlled trial comparing Mitraclip versus surgery in high risk patients. Both surgeries are increasingly being performed in patient populations where we have very little data.” Nguyen adds that “there is essentially no randomised data comparing TAVI versus surgery in a 65 year-old patient with a bicuspid aortic valve while recognising that the average age for the low risk trials was 73 and bicuspid valves were excluded yet TAVI technology is increasingly performed in this cohort.”
In his concluding remarks, he again pointed to the need for collaboration across the heart team to drive better patient outcomes, adding: “We need to be very cautious against creep—we need to know the data, know the limitations, we need non-industry sponsored trials, and we need to be incentivised to treat patients and not generate RVUs [relative value units] and, ultimately; we need to do the right thing.”
This message was shared by Davide Cappodano (University of Catania and Policlinico-Vittorio Emanuele, Catania, Italy), who chaired the discussion session. “As a cardiologist I totally share this message that we want to know more about the procedures that we offer to the patients and I think the heart team must be informed about the pros and cons of each procedure,” he commented. “Surely one of the things we want to know about TAVI is the long-term data especially in lower risk populations and younger patients.”
Nguyen’s presentation came after Thomas Modine (Lille University Hospital, Lille, France) offered EACTS attendees insights from the Cutting Edge registry, which looked at outcomes of mitral valve surgery after edge-to-edge transcatheter mitral valve repair. “It is a very effective therapy, but it is still unoptimised in some sub-categories of patients that we have to address,” he said.
“After 100,000 transcatheter mitral valve edge-to-edge repairs performed worldwide, some patients are still are not meeting the needs of treating this pathology, and there is a lack of multi-institutional, longitudinal data on mitral valve surgery itself. This is why this multicentre registry was initiated.” The Cutting Edge registry reviewed data from patients who had undergone mitral valve surgery after transcatheter edge-to-edge repair. Patients were stratified according to the timing relative to the procedure as either aborted, acute or delayed cases. MValve Academic Research Consortium-2 outcomes at 30 days and one-year were evaluated.
According to Modine, data from the registry on the risk of mitral valve surgery after transcatheter-edge-to-edge repair is non-trivial, but he commented that the data could prove valuable for further research to improve these outcomes. He said: ”We need more patients to be included of course, these are introductory results but show that it is not always easy to achieve a surgery after Mitraclip failure and our duty and responsibility is to see how or what we could improve within the confinement of a heart team, and I think this heart team discussion is very important to do a priori, and with accumulated data and to be able to offer to the patient the best treatment.”