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Following the cutting edge...

EAPCI Column - November 2011

Last month, one of the most trend-setting interventional courses took place in London under the direction of Martyn Thomas. PCR London Valves, an EACPI endorsed programme, topped 1,050 participants to take its place as the foremost event concentrating on valve disease.

The EAPCI was pleased to be associated with such a course, an endeavour which met with a tremendous and positive reaction from both attendees and industry.

The structure of the course itself was exemplary, bringing together the leading international specialists in valve disease. Topics were illustrated by live cases, and sessions explored complications, innovative technologies, and data from registries and trials. TAVI accounted for 80% of the focus. One special part of the programme which I found highly practical, is the innovative “Learning the Techniques” (LTT) sessions. The LTT sessions took place throughout the day in a single room where participants concentrated on all aspects of the state-of-the art in TAVI. The first LTT began in the morning covering the topic of imaging patients “before, during and after” the procedure, followed by a session on gaining access and achieving closure, then deployment of the transcatheter aortic valves and finally how to do a valve-in-valve procedure.

Why this focus on TAVI?

For me, TAVI is important because it is a veritable breakthrough, attacking the foundations of our specialty. I believe it is the most important new technique of the last 20 years, the others being all “coronary”. There were balloons, bare metal stents, there were drug-eluting stents – the next step will be bioresorbable stents – but all are in the same line of reasoning. In TAVI, we are dealing with something totally different, a break in this continuum in a way that can profoundly affect our daily practice. It is a paradigm shift, but what precisely is the full potential for this technique remains to be seen. We ask ourselves what do we really know today about TAVI? Could it in some ways replace surgery? Perhaps, but we are still far from all the answers to these questions, still, one thing is clear: to advance TAVI we must work together; our multidisciplinary approach should include cardiologists, interventional cardiologists, cardiac surgeons, anaesthetists and geriatricians – which is why the concept of the Heart Team is so important. It is through the Heart Team that we can extend the limit of our knowledge and understanding of this technique, methodically moving that fine line which separates indication from contraindication. We have to move this line slowly, basing our decisions on available data, and by working as a Heart Team we can accomplish this with the rigour demanded of us. We cannot do this alone, without the input of cardiac surgeons, and we must continue to follow the data, following the guidelines – which themselves are based on data – in order to advance.

When you look at TAVI today you will see that globally the complication rates are decreasing. When you look at the access site complications – the bleeding complications – you will see that these too are decreasing, both by our experience in patient selection as well as our experience in doing the procedure itself. Technology is also playing a role, with smaller devices, now 18 Fr and in the future, perhaps 16 Fr, but there are still critical issues that require answers. Problems with the access sites, problems of stroke, of paravalvular leaks, of valve durability… all these are areas that require further attention. For instance, the nature of the degeneration of the valve remains unknown: will it occur at the same time or earlier than aortic surgical bioprothesis valves? We do not have these answers, yet.

To respond to these questions we need data and more data, step-by-step, carefully following updates from on-going trials and registries as we did during PCR London Valves: the UK, Italian, German and French registries, the American and Asian perspective and experience as well. Carlo Di Mario presented a call for a unified European registry. There are also the new trials, PARTNER 2 and SURTAVI, whose goals are similar: to compare the results of a percutaneous procedure to a surgical intervention. Here we attack the next step, looking at intermediate risk patients and not high-risk, not the inoperative patients we have focussed on in the past, but instead, seeing the possibility of TAVI as a viable therapeutic option for those at lower levels of risk. For now we must wait for the results of these trials and carefully analyse them; then and only then, if the results are positive could we begin to open the indications; at the present time, however, it is much too early.

An EAPCI endorsed educational meeting

In underlining the importance of TAVI as well as the growing interest on the part of fellow interventionalists to know more about it, we see why the EAPCI would endorse a course focussing on this subject. The concept of TAVI is extremely important in itself, and the quality of the educational programme and objectives of PCR London Valves were excellent. If we look at it from another standpoint, the TAVI procedure is a young interventional technique, and as in all young procedures, we naturally need to train, educate and inform interventional cardiologists about this new technique.

This EAPCI is committed to actively working with these types of educational programmes. We, as an association, ask ourselves what this education should be, what is the nature of the knowledge we are trying to promulgate? What are the current data, the remaining critical issues?

What are the new technologies? What are the new trials in perspective...and for what new indications? A course such as PCR London Valves does this, perfectly mirroring the EAPCI’s commitment to accessible education that responds to the needs of our members and informs them, whether they are advanced practitioners or the next and emerging generation of interventionalists.

So it is appropriate that the EAPCI endorse – and organisations such as the European Board for Accreditation in Cardiology (EBAC) offer credits – for such a course and for such a seminal topic. With this last meeting, PCR London Valves has now shown itself to be the leader in the field of valve disease today... certainly first in Europe, and most likely internationally as well. We are pleased to participate in its success, but above all excited by the contributions it can make for the future of our specialty.


EuroIntervention 2011;7:777-779