Transcatheter procedures in structural heart disease – The
surgeon stepping-in.
Nelson A. Hossne Jr, MD, PhD, and Walter J. Gomes, MD, PhD
The seismic impact of transcatheter interventions is rocking the
spectrum of structural heart disease (SHD) treatment, with the
compelling and attractive appeal of minimally invasive procedures and
fast-track discharge. The trend is relentless and continual innovation
comes to our doors nearly on a daily basis.
In this issue of the Journal, Litwinowicz and colleagues describe their
trailblazing experience in 223 consecutive patients in whom they
performed left atrial appendage occlusion (LAAO) via the percutaneous
route. All interventions were performed by surgeons, who had undergone
pre-training in a simulation model. Soon thereafter, they were able to
achieve outcomes that were comparable to those obtained by experienced
interventional cardiologists [1].
However, their conclusion that cardiac surgeons should be trained in
both types of LAAO, endocardial and epicardial procedures, is shy and
restrictive. Extrapolating for the entire field of SHD, which is
blossoming ahead, the message to be conveyed is that cardiac surgeons
must be trained and embrace every aspect of SHD.
The unique surgeons’ training and skills in open-heart surgery make
their contribution to perfection and safety of SHD treatment, which are
potentially exceptional and distinctive. In addition to percutaneous
interventions skills, the possibility to offer alternative therapies is
at hand, such as minimally invasive, and complex redo interventions.
Because many patients with SHD have multiple structures affected by the
disease, surgeons are also equipped to provide complete multicomponent
therapy to each of these structures in one setting [2]. And proper
and careful procedure selection are mandatory for the ultimate goal of
offering the best to the patient.
The environment for this association is timely, as transcatheter and
conventional surgery must coexist side-by-side in the foreseen future,
with its intrinsic beneficial indications, drawbacks, and inherent
risks. Conventional surgery and its minimally invasive variant will
remain the treatment of choice for a large proportion of patients with
heart diseases, as the shortcomings of percutaneous procedures still
exists in every area. Expanding the scope of percutaneous techniques
carries along additional complications, which have to be addressed
surgically. As for percutaneous coronary intervention, 30% of patients
referred for coronary artery bypass surgery in the United States, had a
previous coronary stenting procedure [3]. Just like TAVI is
expanding to lower-risk patients, many related short- and long-term
complications will be best managed surgically. This is a new and
challenging frontier. Like valve replacement for prosthetic infective
endocarditis, other unforeseen complications will emerge with these
devices, and will have to be treated surgically.
Surgeons with expertise in SHD mastering percutaneous techniques, become
the ideal provider. In countries where tighter labor regulatory policies
are enforced, just a single operator is allowed, and this is the case
for the surgeon.
The authors acknowledge the support of the Polish Society of
Cardio-Thoracic Surgeons issuing certificates to surgeons, confirming
their mastery in performing percutaneous procedures. Like in Brazil,
where the Brazilian Society of Cardiovascular Surgery, partnering with
medical device companies, established ongoing educational and training
programs, with certification for heart surgeons who completed training
and embraced percutaneous techniques. This makes possible the emergence
of many “interventional heart surgeons”. Cardiovascular surgery
societies around the world must strongly support, and not refrain from
offering to its members and local surgeons, the prospect to acquire
these ground-breaking and complementary new skills.
Furthermore, the trend towards referring patients in need for cardiac
procedures to centers of excellence, a policy aimed at achieving better
outcomes and cost reduction, will add elements favoring the insertion
and role of the surgeon in this multidisciplinary program.
Although strongly recommended and demonstrated to provide superior
outcomes, the concept of the ”Heart Team”, where surgeons and
interventional cardiologists work together side-by-side in structural
heart procedures, is breaking apart, as reported from experience in
Europe and the United States. In Europe, there is emerging evidence that
the absence of an on-site surgeon and surgical team from the procedure
did not increase TAVR mortality or morbidity [4]. In the United
States, the value of including surgeons on the Heart Team has been
increasingly questioned, not only for percutaneous aortic valve
procedures but also for other advanced percutaneous interventions, such
as percutaneous mitral valve replacement [5].
The mantra that surgeons have ”missed the boat” in being involved in
percutaneous procedures does not hold to this point [2], as the boat
just hoisted anchors and is set to begin its long journey. This is a
large boat, capable of accommodating many spirited and willing
newcomers.
The self-reliant approach taken by Litwinowicz and colleagues should be
commended and replicated and sets the pace for surgeons around the
world. Despite ingrained skepticism and rejection, we strongly advise
surgeons to be prepared for this ongoing and rapidly changing landscape,
and to seize the timely opportunity. This is an exciting field with
ample space for trainees, junior and senior surgeons to be involved and
exert their leadership. For those who maintain a passive interest, the
boat has already set sail, and the skeptical was already been left
behind.
References
1. Litwinowicz R, Mazur P, Burysz M, Filip G, Wasilewski G, Kapelak B,
et al. Why should cardiac surgeons occlude the left atrial appendage
percutaneously? Journal of Cardiac Surgery, in press.
2. Nguyen TC, Tang GHL, Nguyen S, Forcillo J, George I, Kaneko T, et al.
The train has left: Can surgeons still get a ticket to treat structural
heart disease? J Thorac Cardiovasc Surg. 2019;157(6):2369-2376.e2.
3. D’Agostino RS, Jacobs JP, Badhwar V, Fernandez FG, Paone G, Wormuth
DW, et al. The Society of Thoracic Surgeons Adult Cardiac Surgery
Database: 2018 Update on Outcomes and Quality. Ann Thorac Surg.
2018;105(1):15-23.
4. Eggebrecht H, Bestehorn M, Haude M, Schmermund A, Bestehorn K,
Voigtländer T, et al. Outcomes of transfemoral transcatheter aortic
valve implantation at hospitals with and without on-site cardiac surgery
department: insights from the prospective German aortic valve
replacement quality assurance registry (AQUA) in 17 919 patients. Eur
Heart J. 2016;37(28):2240-8.
5. Wheatley GH 3rd. Commentary: All aboard the transcatheter
express-Road map for surgeons to develop expertise in catheter-based
treatment of structural heart disease. J Thorac Cardiovasc Surg.
2019;157(6):2377-2378