Cath lab may be best location for performing transfemoral TAVR

TAVR has come a long way over the last decade or so. Increasing experience and rapid technical developments have made the procedure safer and quicker to perform. Babaliaros and colleagues demonstrate in this study that in a great majority of patients, transfemoral TAVR can be performed in the cath lab with conscious sedation and local anesthesia without transesophageal echocardiogram and then these patients can be cared for on regular cardiology floors rather than the intensive care unit. More and more centers outside of the United States are adopting this approach, which reduces cost substantially. It appears very feasible in the properly selective patients with careful pre-procedure planning. However, the data published are only from 72 patients, thus we need studies that include a larger number of patients to be confident that this approach can be widely applied, particularly in centers that do not have the extensive experience that the Emory group has.

Another point is that performing a procedure in an environment that is not capable of responding to a true emergency with all surgical means, including immediate availability of the cardiopulmonary bypass and the respiratory support, may result in mortality if a patient faces a catastrophic complication such as aortic dissection or annulus rupture. Having said that, I think a substantial number of TAVR procedures can be performed without general anesthesia or transesophageal echocardiogram either in the cath lab or in the hybrid suite, provided that there is capability to handle all complications effectively and emergently.

The main take away from this paper is that a highly functioning heart valve center with extensive experience treating high-risk aortic stenosis patients can select some appropriate patients who may not need the typical hybrid OR strategy that we’ve employed with open heart procedures. These patients may be able to move along faster with a minimalist, cath lab-based strategy, and there may be cost savings associated with that approach. This savings likely stems from not needing to use a Swan-Ganz catheter and being able to treat patients on more of a fast-track basis with a transfemoral vs. open heart approach. However, these data are observational and from a nonrandomized, retrospective study, so the data should not be seen as conclusive but rather provide impetus for additional randomized studies to more conclusively address these questions.

Within the high-risk TAVR patients, you may be able to find predictors of people who can tolerate not needing extensive monitoring during the procedure. I agree with the researchers in that morbidly obese patients, and those with comorbidities, such as severe lung disease and complex vascular access, as well as those who are mentally challenged and in chronic pain may be best served by the hybrid OR strategy. 

In today’s health care environment, where cost plays an increasingly important role, I do believe that the hybrid OR serves an important function. When performing a valve implantation, for example, it needs to be done in a sterile environment and one that is consistent with an operating room, like the hybrid OR. Also, the hybrid OR has an incredible amount of value for a network, because it’s not just transcatheter valves being performed there, but also vascular procedures, neurointerventions, and other surgical and CV interventions. One of the things a hybrid OR does is facilitate cross pollination between specialties, where people bring less invasive procedures, and transcatheter valves are one of those procedures.