TAVI and Aortic Stenosis with Prof Dion Stub

Prof Dion Stub speaks to Profive Time Medical about TAVI, Aortic Stenosis, and the role of the GP.

Speaker 1 Profive Time Medical (00:00):

Well, we know that aortic stenosis is more than just a sound we are listening for in short cases where medical students, it’s actually a really severe heart condition that if it is untreated, can have a very poor prognosis. So, recognising aortic stenosis in our patients is often the first hurdle to overcome in the next step, of course, is providing appropriate treatment options. And unfortunately, treatment is not always offered in a timely manner, partly due to overestimation of the risks involved with valve replacement. Talking to us today about navigating referral pathways and optimal treatments for our patients with aortic stenosis is Professor Dion Stub, an interventional cardiologist from the Alfred Hospital in Melbourne. Welcome, Dion to drive time medical.

Speaker 2 Prof Dion Stub (00:43):

No pleasure to be here. Thanks for having me.

Speaker 1 Profive Time Medical (00:46):

Let’s talk about TAVI. One of my patients just recently had it and I feel just really close to this procedure right now. How long has it been around and how has it actually developed as a treatment for aortic stenosis?

Speaker 2 Prof Dion Stub (00:58):

So I think the first thing to realise is that severe symptomatic aortic stenosis is associated with significant morbidity and mortality. And aortic valve replacement is really the only treatment that provides long-term benefit from both reduction in mortality and significant improvement in quality of life. And so the trick is to get the right patient to the right therapy. And we know over 30% of patients are not being referred for aortic valve replacement because of concerns around their ability to get through the procedure. And so TAVI, the first procedure was done back in 2002, has had significant improvements with regards to device technology. The first procedure in Australia was 2008 and has really become a mature transformative technology for patients with severe symptomatic aortic stenosis. TAVI began as a procedure to offer an aortic valve replacement initially to those who are prohibitive or high risk for surgery and really attacking that 30% who weren’t being referred, but has now improved to the extent that it’s being offered to patients across the risk spectrum and has really transformed the way we think about aortic valve replacement. And who’s suitable for this technology?

Speaker 1 Profive Time Medical (02:11):

I hadn’t realised it was around since 2002, so I know it was originally developed as an alternative for surgical valve replacement. In those high-risk patients, what are the current guidelines or recommendations and which patients with aortic stenosis should be having a TAVI?

Speaker 2 Prof Dion Stub (02:28):

So Tavis really the most studied surgical procedure in the history of medicine. There are very other few surgical techniques that have undergone seven large scale randomised trials across the risk spectrum. So what began in prohibitively high risk patients, then we had international randomised trials in intermediate surgical risk patients and then ultimately low-risk patients. And so we have over 8,000 patients who have been in these randomised control trials and we have incredibly robust data when we are comparing outcomes of patients undergoing open heart surgical aortic valve replacement versus TAVI. TAVI is a technique that’s done percutaneously most of the time through the femoral artery. In Australia, 99% of the procedures are done under local anaesthetic. The procedure takes about 30 to 45 minutes. Patients are sitting out of bed on the same day of the procedure, mobilising that evening and are being discharged usually between one and three days after the operation and are potentially returning to their normal life within days.

(03:33):

I just had an 88-year-old who underwent TAVI last week and was back playing community tennis within four days of the procedure. So that’s an incredibly different procedural trajectory to, whilst we have fabulous results of open heart surgery in Australia, that’s a very different procedure to a two to three hour procedure being performed under general anaesthetic with a few days in intensive care than usually a week in hospital and potentially being discharged for rehabilitation. And when we look at quality of life outcomes, we know that it takes patients undergoing open heart surgery about six months to return to the same quality of life that the patient will undergoing percutaneous TAVI. So it’s a vastly different procedure with regards to recovery. And then the other crucial aspect is to looking at hard clinical outcomes. And so, we know from this robust data over 8,000 patients in randomised controlled trials that it’s quite different short, short-term morbidity and mortality. And so across the risk spectrum, so we’ve looked at now low intermediate and high-risk patients that you have a reduction in short-term mortality and then importantly you have a significant reduction in morbidity, including reduction in bleeding renal dysfunction, atrial fibrillation and recovery.

Speaker 1 Profive Time Medical (04:52):

And in terms of the different patient experiences that they can expect from TAVI versus surgical valve repair.

Speaker 2 Prof Dion Stub (04:59):

Yeah, so again, the treatment for severe symptomatic aortic stenosis is an aortic valve replacement. And then it’s just a question of how that’s done. Is it going be done percutaneously through a TAVI or is it going be done with open heart surgery through a surgical aortic valve replacement? And then the key considerations there are appropriate anatomical workup. And so, what will happen is once the diagnosis has been made, so generally from a GP perspective, auscultation of the heart picks up the murmur, arrange an echocardiogram. Once you have more than moderate aortic stenosis, then I think that would be the time to think about referral to a cardiologist. And then from there, once it’s being deemed that the patient’s suitable for workup, there’s a series of anatomical assessments that need to be made to work out what’s the best option for the patient. And so those tests will include an invasive coronary angiogram to look at. Is there concomitant coronary artery disease that again may sway the decision making towards, we could think about percutaneous coronary intervention combined with TAVI versus coronary artery bypass graft surgery combined with surgical aortic valve replacement. So we do the coronary angiogram. The other key test is a CT Aortogram, which is important for both TAVI planning and surgical AVR planning. But that CT aorta is really where we have a very close three-dimensional reconstruction of the aortic valve aorta and IPH femoral vessels to decide what’s the best approach and what’s most anatomically suitable for the patient.

Speaker 1 Profive Time Medical (06:32):

So which health professionals are usually involved in like a heart team and what is the role of that team for the patient?

Speaker 2 Prof Dion Stub (06:39):

So I think one of the great aspects that came through the rigorous randomised trials that were TAVI compared to open heart surgery was the concept of the heart team. And so, TAVI is the only procedure in Australia where it’s mandated that before a patient undergoes TAVI, they have to boot referred to a heart team, which is really interesting because our patients undergoing surgical aortic valve replacement through a quirk of history or regulatory framework don’t have to be referred to a heart team. And I think that’s a really important distinction. The heart team comprises of a multidisciplinary group of experts who are making appropriate recommendations to the referring cardiologist around what’s the best treatment for the patient with severe symptomatic aortic stenosis. And so that typically will comprise an interventional cardiologist, a cardiothoracic surgeon, generally a TAVI nurse, case manager or coordinator, and then other extended members of the team that will differ depending on this institution. You’ll have general cardiologists, anaesthetists, geriatricians, radiologists, or imaging experts.

Speaker 1 Profive Time Medical (07:49):

What are the main benefits of that mode of assessment for treating aortic stenosis?

Speaker 2 Prof Dion Stub (07:55):

So, we’ve learned that whilst TAVI began, again around the whole concept of risk, we now know that Tavis an excellent option across the risk spectrum for both low intermediate and our high-risk patients. And so that it all comes down to anatomy based on our CT coronary angiogram and echocardiography anatomically what’s the best interest of the patient. So that may be comparing TAVI or a transcatheter approach compared to open heart surgery. But then even within TAVI, there’s some subtleties around what’s the best TAVI bioprosthetic valve to choose for that patient based on their anatomy. And that’s where the MDT really provides objective evidence-based recommendations for every patient.

Speaker 1 Profive Time Medical (08:38):

So who should be referring to that multidisciplinary team? Is it us the GP, or is it you, the cardiologist?

Speaker 2 Prof Dion Stub (08:43):

So I think the key thing is one that we’re not missing patients with severe symptomatic aortic stenosis. And we come back to the importance of early auscultation for our patients as well as echocardiography. But then once the diagnosis of aortic stenosis is made, then referral to a cardiologist with expertise in managing aortic stenosis. That’s traditionally an interventional cardiologist who can then refer the patient to the M D T, which again is mandated before any TAVI is performed in Australia.

Speaker 1 Profive Time Medical (09:13):

Such a great talk about TAVI for aortic stenosis or severe aortic stenosis and or the role that GPs play. What are the key messages for GPs to take home from our chat today?

Speaker 2 Prof Dion Stub (09:24):

So I think the first and fundamental message is we have to be osculating our patients. We’ve had three years of potential telehealth over Covid. We have to get our patients into the surgeries auscultate. When we diagnose a murmur, we refer for an echocardiogram and anyone with significant valve disease, we think about appropriate referral for cardiology assessment. The other is that our approach to aortic stenosis has completely transformed over the last decade in Australia and around the world. And that TAVI is a low-risk, fully percutaneous option performed under local anesthetic, 45 minutes with rapid return to activities of daily living and has transformed the journey for patients undergoing aortic valve replacement.

Speaker 1 Profive Time Medical (10:08):

Professor Dion Stubs, thanks so much for joining us on Profive Time Medical.

Speaker 2 Prof Dion Stub (10:11):

Thanks for having me.