The Great Debate
Everyone is talking about the EuroPCR Great Debate! This year the debate focused on renal denervation for the treatment of resistant hypertension. This technique has become a hot topic for discussion since receiving the 2011 EuroPCR Innovation Award. Resistant hypertension has also become a controversial subject with experts struggling to reach a consensus regarding screening, diagnosis and treatment of the condition.
Yesterday’s session began with a live demonstration of the technique, conducted by the team of Jean Fajadet from Toulouse, France, and Robert Whitbourn from Australia. Members of the audience were impressed by the care, precision and elegance of this procedure. The case focused on a very young patient (38 years old) who had shown resistance to five different hypertensive drugs. This is a particularly interesting case as some experts believe that younger people may respond more favourably to this procedure than elderly patients who tend to have stiff arteries.
The expert panel, facilitated by William Wijns, brought a wide range of experience to the debate from the fields of nephrology and interventional medicine:
- Professor Pierre-François Plouin - Professor of Medicine and Hypertension, Paris, France
- Dr William McKane, Consultant Renal Physician, Sheffield , UK
- Professor Isabelle Durand Zaleski, Professor of Public Health, Paris, France
- Dr Felix Mahfoud, Cardiologist, Hamburg, Germany
- Professor Jean Renkin, Cardiologist, Brussels, Belgium
- Professor Thomas Zeller, Cardiologist, Bad Krozingen,Germany
Filmed interviews brought further insights to the discussion from opinion leaders in public health and preventative medicine. The depth of discussion and expertise provided by the panel delivered a highly informative session that was enjoyed by both the audience and expert panel.
The risks and benefits of this technique were reviewed in light of current efficacy and safety data, specifically focusing on the ongoing SYMPLICITY HTN-3 clinical trial currently taking place in 90 centres across the US. Current safety data are encouraging but further consensus is needed regarding acceptable patient outcomes in terms of blood pressure reduction. Long-term data will be critical in order to provide a health economic argument for this procedure.
Finally, the group provided their personal insights regarding future applications for this technique. Approximately 5,000 patients have undergone this procedure to date and few alternative interventions are available. There seems to be no progress in terms of other pharmacological options for these complex patients. Alternative indications for renal denervation include metabolic syndrome, atrial fibrillation and arrhythmia. The potential benefits of this technique are extremely exciting and will no doubt continue to stimulate debate as we move forward.
10 years of TAVI
Pioneered by Alain Cribier, transcatheter aortic valve implantation (TAVI) has saved the lives of many cardiac patients. Progress from initial concept to the real world has been a highly challenging but fascinating adventure and the procedure is here to stay.
Calcified aortic stenosis (AS) is the most common valve disease in developed countries where incidence is increasing due to the aging population. Around 6% of people over 65 years old are affected and this figure increases significantly with age. Once symptoms appear, the outlook is poor with a mortality rate of around 80% at two years. Aortic valve replacement has, for some time, been the only treatment available but a third of patients who need to undergo treatment cannot undergo this procedure due to poor health, age and/or co-morbidities which significantly increase the surgical risk. The recent development of aortic valves that can be fitted without an open surgical procedure, therefore, represent hope for thousands of these patients.
In 2002, a 57 year old man received the first aortic valve implantation in France. The procedure was conducted by Alain Cribier who describes this as ‘the best day of his life’. Since then, approximately 50,000 patients have undergone TAVI in more than 500 centres across Europe. Recent studies in the US have also shown that the technique is as effective as surgery and significantly improves survival rate for patients compared with medical treatment alone.
The concept for this ground breaking technique was originally conceived in 1985 when Professor Cribier's team performed the first aortic valve balloon dilation. Sadly at that time, many patients over the age of 75 years were dying because they were considered too old for cardiac surgery. Aortic balloon valvuloplasty provided an alternative solution although valvular restenosis has become an established complication of this technique. Convinced there must be a solution to this problem, Professor Cribier conducted post-mortem studies and developed the concept of a stented valve. Working with his American colleague Martin Leon and engineering experts Stan Rabinovich and Stan Rowe the group formed their own company to develop a prototype valve, which was successfully implanted in sheep and bovine vessels. This prototype went on to become the valve that was used in the first human procedure.
TAVI now plays a major role in the management of patients with AS and can be considered the standard of care in non-operable patients, as well as a valuable alternative for patients at high surgical risk. Keys to success are optimal multidisciplinary collaboration for patient screening and procedures, and formally trained and experienced physicians. Each indication for TAVI is a matter of clinical judgment and it should be reserved for the subset of patients in whom a good outcome is likely. Cardiologists, cardiac surgeons, anaesthesiologists, imaging specialists, geriatricians, nurses and technicians have learned to work together in highly effective partnerships to make TAVI possible, safe and successful with optimal patient outcome.
Within five years, an extension of indications to lower-risk patients can be expected, as well as an explosion of centres and investigators worldwide. Simplified and safer techniques will soon be available, with rapid and consistent technological improvement. Although work still needs to be done to improve techniques and outcomes further, the future of TAVI looks bright.
Professor Cribier is now working with colleagues across the globe to train teams in this technique. “The procedure has a 95% success rate and we have trained 200 teams at CHU Rouen to use this technique. It has saved the lives of countless patients already and we hope it will continue to do so during the next 10 years”.
Life saving primary PCI rising in Stent for Life countries
Life saving primary percutaneous coronary intervention (PPCI) treatment is increasing in countries participating in the Stent for Life Initiative. These achievements and other activities will be revealed at EuroPCR 2012, 15-18 May, in Paris, France. EuroPCR is the official annual meeting of the European Association for Percutaneous Cardiovascular Interventions (EAPCI), a registered branch of the European Society of Cardiology (ESC).
The Stent for Life Initiative is driving equal access to PPCI in heart attack patients across Europe. The mission is to improve the delivery of care and patient access to the life saving indications of PPCI, thereby reducing mortality and morbidity in patients suffering from acute coronary syndromes (ACS). The objective is to increase the use of PPCI to more than 70% of all ST elevation myocardial infarction (STEMI) patients, achieving PPCI rates of more than 600 per one million inhabitants a year. To do this the aim is to offer a 24/7 PCI service at all relevant facilities to cover the country population need.
“There is great progress in all Stent for Life countries where we are promoting primary PCI,” says Professor Steen Kristensen (Aarhus, Denmark), Stent for Life Initiative Chair. “All countries are reporting back now that the numbers of patients treated with primary PCI, the best reperfusion therapy, is increasing.”
The initiative aims to reduce delays in patients seeking treatment and reduce delays in the system so that patients who have a heart attack get reperfusion therapy as quickly as possible. Women have even greater delays than men in accessing lifesaving PPCI. The Stent for Life Initiative is tackling this disparity through a collaboration with Women in Innovations (WIN), a global group of female interventional cardiologists addressing gender disparities in cardiovascular care.
The Stent for Life Initiative is holding a number of sessions at EuroPCR, including a plenary session on Thursday, 17 May on how to optimise the delivery and quality of PPCI. Journalists are invited to visit the dedicated Stent for Life Initiative booth (M58, Level 2) where they can talk to people implementing Stent for Life in their own countries and hear the results of the ACT NOW.SAVE A LIFE public campaigns.