Clinical Heart and Vascular Center
Catheter-Based Therapies: A Glimpse Into the Future
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By Dharam Kumbhani, M.D., Associate Professor of Internal Medicine; Section Director, Interventional Cardiology
I was honored and delighted to represent UT Southwestern at multiple venues during the 2019 AHA Scientific Sessions. I was a panelist and discussant at one of the Late-Breaking sessions that was focused on aortic stenosis. Specifically, I was asked to provide a commentary on a large comparative-effectiveness study from France that compared balloon-expandable valves to self-expanding valves for TAVR. This is a controversial topic, and there are very limited randomized controlled data to help guide physicians in choosing between the two; yet, on a daily basis in clinical practice, we need to make decisions about which valve to implant. This thought-provoking and hotly debated study suggested that balloon-expandable valves resulted in less paravalvular regurgitation and lower short- and long-term mortality compared with self-expanding valves. I discussed the possible biological feasibility of these findings but also expressed caution about making causal inferences from observational studies. Ultimately, I emphasized the urgent need to have adequately powered clinical trials to determine if one type of valve is truly superior to the other.
I was also a panelist or moderator for two other sessions on hemodynamic support for cardiogenic shock and PCI. This is a field that also badly needs high-quality randomized controlled data to support decision-making. In fact, another late-breaker on this topic generated much debate and discussion at this year’s Sessions. That study was simultaneously published in Circulation and assessed the role of Impella, a device that is being used increasingly yet with marked variability in associated outcomes. What was most noteworthy was that patients receiving Impella had more vascular complications and worse outcomes compared with those receiving an intra-aortic balloon pump. Undoubtedly, these findings will continue to be debated in the upcoming months and again underline the need to have well-powered clinical trials in this space.
“This thought-provoking and hotly debated study suggested that balloon-expandable valves resulted in less paravalvular regurgitation and lower short- and long-term mortality compared with self-expanding valves.”
Without a doubt, the future of catheter-based interventions is bright, particularly in the field of structural interventions. There were several sessions that focused on the existing and emerging evidence for various technologies such as TAVR, MitraClip, etc. There were also good discussions on appropriate patient selection for these technologies. For instance, I spoke about considerations for TAVR among very elderly patients. It is estimated that people older than 80 are one of the fastest-growing segments of the U.S. population. For many of these patients, quality of life is often as important as quantity, if not more so. Understanding the requirements for frailty assessment and ways to engage in meaningful shared decision-making in this patient population are crucial.