Interventional cardiology

Questions over CSANZ position on transcatheter valve therapies

Two new joint CSANZ and Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) position statements on transcatheter valve therapies reinforce the central position of the multidisciplinary Heart Team.

The 2021 CSANZ / ANZSCTS position statement on the operator and institutional requirements for a TAVI program in Australia say the Heart Team will become increasingly important with the expansion of TAVI beyond high surgical risk patients to those at lower risk.

“Additional factors that will need to be considered in younger patient cohorts include the extent of concomitant coronary disease and potential need for future revascularisation, the presence of an associated aortopathy in patients with congenitally bicuspid aortic valves, the likely need for, and long-term consequences of, pacemaker implantation, and options for re-do TAVI or surgical AVR in the event of prosthetic valve degeneration,” the position statement published in Heart, Lung and Circulation said.

The transcatheter mitral valve therapies position statement also says the Heart Team should consider all aspects of the procedure including the management of peri-procedural complications, and appropriateness of emergency surgery.

However an editorial in the journal said the advice may not have gone far enough with the Heart Team only mandated for transcatheter therapies.

“…one could argue that this was also a lost opportunity to formally broaden the focus of the Heart Team to the surgical as well as transcatheter management of aortic and mitral valve disease,” it said.

The editorial, led by interventional cardiologist Dr Allan Davies, said limiting the Heart Team to transcatheter therapies was also contrary to international guidelines.

“While we think it likely there was an initial desire to prevent patients receiving inappropriate transcatheter intervention, with the ever-expanding evidence base for TAVI in intermediate and low risk patients the present arrangement now potentially allows for patients to receive inappropriate surgical intervention,” the editorial said.

“Whether enshrined in the MBS schedule or not, the future of valvular heart disease management is a Heart Team based, integrated approach.”

Dr Davies, from the Hunter New England Local Health District, and his co-authors also questioned the procedural volume recommendations for centres in both the TAVI and TMVr position statements.

They noted that Australia already has more TAVI credentialled hospitals than the UK and most appear to be within metropolitan areas and near existing programs.

“Addressing the clustering of transcatheter centres in metropolitan areas in position statements is difficult. Raising minimum volume standards may be a solution for those in close proximity to other centres and will likely be necessary as we move into treating low risk cohorts.”

The editorial also raised the issue of why TMVr and TAVI, but not surgical mitral valve repair and more complex SAVR , require re-accreditation every three years

“If part of the role of consensus statements is to ensure patients receive the correct therapy, as recommended by a Heart Team, performed by an operator with sufficient volume-based experience, then the societies and the MBS should consider volume-based credentialling for both surgical and transcatheter procedures, with Heart Team review for both as standard.”

The editorial also questioned how strictly credentialing guidelines would be enforced, given complex issues around equitable access to services and the impact of restrictions during the COVID-19 pandemic.

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