The evolution of TAVR: Celebrating 1,100+ procedures at Michigan Medicine

February 27, 2018  //  FOUND IN: Michigan Medicine News,

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When the first transcatheter aortic valve replacement (TAVR) was performed at the Frankel Cardiovascular Center in 2011, no one could have imagined how the procedure would evolve in just a few short years. Not even the team of cardiologists and cardiac surgeons at U-M who have become renowned experts in this minimally-invasive treatment for aortic stenosis and who have performed more than 1,100 TAVR procedures.

Aortic stenosis is a narrowing of the large blood vessel branching off from the heart. For patients who have it but are unable to withstand an open-heart procedure, catheter-based TAVR has proven to be a lifesaver.

But the technology that enables this groundbreaking procedure is only part of the story. The credit for TAVR’s success at U-M is shared far and wide as the program’s founding physicians credit a collaborative team committed to excellence.

Teaming up

Cardiac surgeons George Deeb, M.D., and Himanshu Patel, M.D., along with interventional cardiologists Paul Grossman, M.D., and Stanley Chetcuti, M.D., quickly realized the game-changing importance of TAVR. The procedure typically results in less downtime, faster recovery and a shorter hospital stay compared with patients who undergo an open-heart procedure.

Together in 2010, the foursome traveled to Lisboa, Portugal, where CoreValve — one of the earliest TAVR devices — was being implanted.

“We spent time learning about CoreValve technology, saw some cases and met many colleagues who were doing the procedure,” said Grossman.

Soon after, CoreValve was purchased by medical technology company Medtronic.

“Because of our strong relationship with the company and our involvement in other Medtronic clinical trials, we became very involved in the CoreValve trials,” said Deeb.  “TAVR has proven to be a great form of therapy with a great survival rate. The lack of complications was astounding.”

Deeb’s team would became so integral in the CoreValve clinical trials that today, Deeb, Grossman, Patel and Chetcuti are actively involved as committee members for the trials and as proctors who travel to other institutions to train physicians.

“Our collaborative team is a model for other institutions who look to us for help in setting up the program and learning how to perform the procedure,” said Patel.

But collaboration doesn’t end with these four physicians.

“Our collaborative culture extends to the entire TAVR team and our mutual respect for one another,” said Grossman. “We were committed to building the program as a team, including cardiologists, surgeons, nurses, nurse practitioners, clinical staff, medical records staff, rehab — all working together. This is what adds strength and depth to ensure a quality program.”

Mary Jo Boyle, D.N.P., ACNP-BC, CCRN-K, agreed: “As part of our multidisciplinary team, we all play an integral role in the care of our TAVR patients.” She and fellow nurse practitioners meet with physicians to develop a plan for each TAVR patient and manage care pre- and post-procedure.

Clinical research project manager Jessica Oakley, B.S., CCRP, said the collaborative nature of the TAVR team provides her research group with different perspectives that promote ideas and new ways of thinking. Working as part of the team, she said, “sparks innovation and is one of the reasons we’ve been at the forefront of advancements in the treatment of aortic valve disease.”

Added Chetcuti: “The era of doctors acting in isolation is a thing of the past. A heart team concept is key to the way we care for our patients. Our partners in anesthesia are vital to the work, along with colleagues in echocardiology, electrophysiology, CT radiology and numerous other subspecialties. The teamwork makes taking care of these complex patients possible.”

Merging tech and talent

While technology continues to improve TAVR procedures, technique and physician input likewise fuel technology. For example, the creation of smaller catheters has led to the invention of retractable valves that can be repositioned during the procedure, resulting in decreased paravalvular leaks and better positioning techniques.

The benefit of merging teamwork with technology extends to the new Aikens Hybrid Suite at the CVC.

“Our hybrid operating room gives us the perfect environment for performing TAVR cases,” said Deeb. The TAVR team performs an average of 10 procedures a week. “The OR enables us to use the latest imaging and measuring tools to realize maximum high-quality outcomes. And if there’s an issue with the TAVR procedure, the room can be transformed into a surgical operating room at the push of a button.”

Looking to the future

With TAVR now being offered to those at moderate risk for open surgery with current clinical trials for low-risk patients, there is new emphasis on TAVR as a replacement for open-heart surgery. In the not-too-distant future, Deeb said he believes TAVR will replace open surgery for aortic stenosis patients who do not have a genetic condition. And within 10 to 15 years, he predicts TAVR will be used to treat most aspects of aortic disease.

“We’re also looking into how younger TAVR patients with aortic valve disease will do in the future,” said Grossman. “For patients in their 60s and 70s, we need to plan for their lifespan: How will these TAVR patients do 10 or 15 years from now? These are the kinds of questions we now must consider.”

Setting new standards

When all is said and done, Grossman said the success of the U-M TAVR program is due to a focus on teamwork, talent, technology and the patient experience.

“We quite intentionally built and staffed the program to make it a true, full experience for patients and their families — from the day of referral they see that the program is for them,” Grossman said. “We explain all the steps and all questions are answered so patients know what to expect. In the end, they feel cared for.”

“TAVR, by virtue of its success, has opened doors to novel and exciting treatment options for other heart valve conditions,” said Chetcuti. “The work we have put into our TAVR program has set new standards for the follow-up and care of all heart valves patients.”

Deeb concurred: “Our team’s passion is to advance medical care to promote health and wellness for patients. This effort is very rewarding when we can accomplish our goals of promoting innovation for better health care for everyone.”

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