Dr. Mariell Jessup,
A joint session between the European Society of Cardiology and the American College of Cardiology.
Pro: M. W. Bergmann (Hamburg, DE) Contra: J B McClurken (Philadelphia, USA) Professor Bergmann argued that despite clear indications for aortic valve replacement (AVR), approximately 30-50% of patients are denied AVR because of perceived concerns with open heart surgery, especially if the patient has multiple co-morbidities. TAVR (transcutaneous AVR) has already been shown to allow AVR in patients considered too ill for surgical AVR (SAVR), with similar mortality, but an increased incidence of stroke. He maintains that technical improvements in TAVR should reduce the incidence of stroke associated with the procedure. Dr. Bergmann said that TAVR has already been very well accepted as a useful procedure in Germany, especially because the quality of life after TAVR can be markedly improved. Professor McClurken acknowledged the need for safer surgery but argues that the reported mortality in the TAVR versus SAVR trials with SAVR was really low, at 3%. In addition, he expressed concerns with the long term results of TAVR, especially the incidence of aortic regurgitation with TAVR. He cited two recent surgical reports of SAVR in elderly patients with aortic stenosis, one from Switzerland and the other from the USA. Both showed a very low operative mortality and a very low stroke rate.
Pro: R Starling (Cleveland, USA) Contra: P J Mohacsi (Bern, CH) Professor Starling cited the huge unmet need for patients with advanced heart failure, despite the success of heart transplant. Using recent data from the American INTERMACS registry, he showed excellent survival in patients implanted with the continuous flow VADs (ventricular assist device), with one-year survival nearing 90% in many patients. Moreover, he noted excellent improvement in quality of life with the newer generation of VADs. A highlight of his debate was a video he showed of a patient following her VAD surgery-she was very convincing. Professor Mohacsi pointed out that in most series (even in INTERMACS) only 17% of all eligible patients actually had a permanent VAD implanted (destination therapy). He outlined the causes of death after VAD and showed that the stroke rate was still quite high, even with the newer generation of VADs. He also discussed the troublesome problems of GI bleeding after VAD surgery, and the progressive problem of aortic insufficiency in these patients.
Controversial issues in advanced cardiac disease
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