CME/CEU Activity: The Promise of a Minimalist Approach in Transfemoral TAVR: Into the Cath Lab

In order to complete this educational activity, please visit the website to answer questions and obtain your certificate: https://www.cathlabdigest.com/TAVRMin

I. Vinod H. Thourani, MD

CLD last featured the Emory Structural Heart and Valve Center in October 2012¹, and at that time, the transcatheter aortic valve replacement (TAVR) program had completed 400 procedures. Where are you now?

Right now, we are north of 850-900 cases. We are fortunate to be doing a large volume, and have grown from one campus, where we originally started in 2007, to a total of three campuses: Emory University Hospital, Emory University Hospital Midtown, and Emory St. Joe’s Hospital. It has been good for growth and good for the patient, because it allows us to reach different geographic areas. Dr. Babaliaros and I are the co-directors of the Structural Heart and Valve Center. We have built a team of five surgeons and five cardiologists (including myself and Dr. Babaliaros), who are the valve implanters for these three hospitals.

We are truly grateful to our team of cardiologists (Drs. Devireddy, Mavromatis, Stewart, Lippe, and Block) and cardiac surgeons (Drs. Leshnower, Sarin, Macheers, and Guyton). I also want to stress the incredible relationship we have with our cardiology echocardiography colleagues. Along with emphasizing our strong and collaborative cardiology relationship, we would like to point out that at Emory University, we have surgeons actively performing transfemoral cases from initial femoral access, to valve deployment, to deploying the closure devices. Moreover, we have had cardiologists performing mini-sternotomy incisions and deploying the transapical TAVR valve in the hybrid room. Most recently, the other day Dr. Babaliaros, a cardiologist and the co-director of the Emory Valve Center, was placing stitches in a ventricle during a transapical TAVR. We think that this interdisciplinary approach is probably the pathway of the future. It is a true hybrid team and is a true testament to the collaborative relationship between cardiology and cardiac surgery at Emory University. The philosophy we have at Emory is that with the exception of cardiologists not doing open valve replacement and the cardiac surgeon not doing a coronary stent, everybody is interchangeable. That is a philosophy we think is important for a true hybrid team. As a surgeon, I do open surgical aortic valve replacements, I do transaortics, transapicals, transcarotids, and I do transfemorals. At this point, I feel very comfortable doing any TAVR case with a cardiology resident and Dr. Babaliaros feels comfortable doing any TAVR case with a cardiac surgery resident. Specifically for cardiac surgeons, we feel it is important for them to have all the wire skills required to do TAVR valve work. 

Can you tell us about the minimalist approach to TAVR?

Alan Cribier, in Europe, has been doing a minimalist approach long before us, so the idea came from him. Dr. Babaliaros had trained with Dr. Cribier in 2004. We decided to try some of the things in the U.S. that Dr. Cribier is doing in France, which is basically what we call the minimalist approach (a name which doesn’t actually reflect the complexities of this type of procedure). A minimalist approach means we are performing a percutaneous transfemoral TAVR procedure in the cath lab, without some of the things typically done in hybrid operating room (OR)-based TAVR procedures, such as transesophageal echocardiogram and the use of general anesthesia. Minimalist approach patients receive intravenous (IV) sedation and local lidocaine only, and if the procedure goes well, the patient goes to a recovery area, and then goes straight a private room, skipping the entire intensive care unit (ICU) step. As a result, length of stay may be able to be decreased. We have now successfully completed over 200 cases of this type of procedure. Overall, it has also allowed us to increase throughput, and as our study demonstrates², cost can be diminished quite well with this approach. 

What staff is working in the minimalist approach cath lab TAVR cases?

We have the same cath lab staff that perform our cases in the hybrid OR and the cath room. For instance, if we post three TAVR cases that day, we will start off in the hybrid OR with the cath lab and OR staff, doing a transapical TAVR. We will then use the same cath staff that goes upstairs to the cath lab and we will perform a transfemoral minimalist approach. Later, we will come back downstairs and do another TAVR case in the OR if it is a non-transfemoral alternative access case. If it is another transfemoral, we will stay in the cath lab. In this instance, we can finish three cases very expeditiously. 

Pre and post procedure, along with Dr. Babaliaros and myself, we have one nurse practitioner and one physician assistant (PA) dedicated to our practice that are taking care of all our TAVR patients, including the minimalist approach patients. What is unique about Emory is that we also have 4 dedicated TAVR residents. We have two dedicated research valve fellows (one in cardiology and one in cardiac surgery) and two dedicated clinical valve fellows (one each in cardiology and cardiac surgery). So we have one mid-level provider and one fellow on each campus that are dedicated to our TAVR patients. 

How do you determine if a patient is a candidate for the minimalist approach?

Dr. Babaliaros and I made the original distinctions ourselves, and the two of us made the final decisions as a heart team. First, as we planned for this approach, we found that in our transfemoral cases, there was not a very high rate of conversion of transfemorals to cardiopulmonary bypass; in fact, we still haven’t had that happen. Second, less than 1% of our patients required an open surgery after a transfemoral was done. In reviewing our transfemoral experience over hundreds of patients, we felt confident going into a cath lab. We had done a couple hundred transfemoral TAVR cases before we decided to go down this pathway. I would stress that it is not a pathway for an operator who has done, for example, 10 transfemoral TAVR cases. We also felt very comfortable with the echo component. The echo team in the cath lab is the same as in the hybrid room. Our teams have not changed at all. Our same team has done hundreds of cases together, and we don’t want the message to be sent out that anyone who does TAVRs can do the minimalist approach. We feel it is important to have done a few hundred cases in order to gain experience. 

What are some of the exclusion criteria?

We exclude patients with a very marginal femoral artery, because of the chance of iliac artery rupture. Patients with a very low-lying coronary artery, those that might require a stent in the left anterior descending coronary artery or the right coronary artery, are excluded, because sometimes these patients crash very quickly and bypass support is required. Since cardiopulmonary bypass circuitry is not available in the cath lab, we avoid these two populations.

Why not use transesophageal echo?

There are some sites in the U.S. that actually do transesophageal echocardiograms in awake patients, but the majority of sites tend to feel more comfortable with it in intubated patients. In the minimalist approach, we stay away from it completely by using transthoracic echo. Patients do not need to be sedated to do a transthoracic echo, because the probe is just put on the chest. When we are using fluoroscopy, the echocardiographer backs out their hands; when we are not using fluoro, they can look at the heart. Echo is mainly used to assess placement of the valve, but the other reason we use echo is to look for regurgitation and paravalvular leak.

The study also showed a big impact on post procedural stay and cost, with length of stay reduced by 2 days for minimalist approach patients. There was also a significant cost reduction with the minimalist approach. Was that in part because of the reduction in length of stay?

Yes, but we can only hypothesize that, although I will say that the valve cost is exactly the same, no matter the type of TAVR procedure. In the study, we did not exclude the ICU step as frequently as we are now. Currently, we are excluding ICUs on a much more regular basis, so I see the cost disparity between the two procedures as being even greater. 

The push lately has been toward earlier ambulation for TAVR patients. 

I agree, and it is much easier when the patients don’t go to the ICU. In those patients who undergo general anesthesia, the lingering effects of medications in this elderly population may postpone early mobilization. Another important aspect of the minimalist technique is that we do not place a Swan Ganz catheter. At Emory, if a patient has a pulmonary artery catheter, they are required to go to the ICU, which is not required in the minimalist TAVR patients. Once patients have had their 6 hours of lying still, as with a regular heart cath, then they are able to ambulate. When I make rounds in the evening, sometimes the patients are sitting in a chair after their valve implantation. This is great, because it is not what we would have normally done 5 years ago. Early ambulation is important, especially for the elderly population we see for TAVR. When I sit down and communicate my expectations to our minimalist cath lab patients, I tell them, “If everything goes okay, I’m going to send you home the next day.” I set the bar really high, and they are excited about it. The idea that they may be able to go home 24 hours after valve surgery is huge, and we have gotten zero pushback from patients. We encourage the patients and the families to stay proactive in their care. 

Can you share more about the varied points of access in use at Emory?

Our TAVR access routes have been done a total of 5 ways. When a patient comes to us, our first choice of a route is transfemoral. It is easiest on the patient. The next route we take is either transapical or transaortic. Generally speaking, if there is no previous sternotomy, then we go the transaortic route. If the patient has severe chronic obstructive pulmonary disease (COPD) or if they have a virgin chest, then we go transaortic. If the patient has a previous coronary artery bypass, then we go the transapical route. Historically, transapicals are the second route of choice, because most of these patients have had a previous surgery. Next is the transcarotid route, with which we now have done 14 cases and have one of the largest, if not the largest, North American experience. Transcarotids are done in patients where we can’t do transaortic or transapical, or obviously, transfemoral. We make a small incision in the right carotid artery. Our results have been excellent with this technique and we have a 100% discharge survival in this small cohort. We have done one case of the transcaval route, and that was just two weeks ago. Transcaval allows us to go through the right femoral vein. Emory is a unique site, because we can do all five routes of access interchangeably.

How does access choice affect valve manipulation?

The transapical and the transaortic routes do have less required manipulation — the valve is closer, and consequently, studies have shown that there is less paravalvular leak in transapical and transaortic cases than there are in transfemoral. This may in part be due to the fact that the manipulation of the valve is more of a one-to-one relationship — you move it, it moves, because the distance is shorter. 

Thus far, we have seen excellent, very low rates of paravalvular leak in the minimalist approach.

In the October 2012 interview, you had mentioned the use of balloon sizing to help estimate the size of the aortic annulus.³ Is that still in use?

Yes, although we use computed tomography (CT) more commonly than just a few years ago. We don’t only go on echo for sizing. Generally speaking, both our Emory radiologists and we will do the sizing. We also use an outside company to read the CT and give an independent recommendation. If both sizing recommendations are congruent, meaning that Emory’s CT analysis and an outside CT analysis are read as the same, then we generally use that size as determined by the CT, with confirmation by echo. If there is a difference — for instance, the outside company thinks we need to put in a 26 mm valve and we think we need to put in a 23 mm valve, then we will do a balloon sizing, as pioneered by Dr. Cribier. This discongruence happens quite a bit actually, so somewhere around 30% of the time, we are still doing balloon sizing.

Any final thoughts?

First, a minimalist approach isn’t for everybody coming right out of the gate. If someone has done 10 TAVRs and starts doing this procedure, there will be a lot of complications. A minimalist approach is where we see the future, but it is important to have the intricacies of the valve and echocardiography ironed out before attempting this process. Second, our study shows that with surgeons and cardiologists working together, that a minimalist procedure is not taking away from or adding to one specialty more than the other. It is all of us working together. There are surgeons in the room doing these procedures side-by-side with a cardiologist. It is a true heart team approach. Third, and most importantly, the minimalist approach is the easiest approach on the patient, decreasing the morbidity and mortality associated with TAVR. 

II. Vasilis C. Babaliaros, MD

Dr. Alain Cribier in France has strongly influenced the work being done at Emory. Can you share your history with Dr. Cribier?

Our relationship with him goes back to 2004. When I finished my training in the U.S., I took an extra fellowship with Dr. Cribier. I was his first American fellow, but he had fellows from all over the world, mostly India and the Far East. Dr. Cribier pioneered valvuloplasty back in the mid-1980s, so he had many visitors. He started with aortic valve implantation in 2002. My fellowship year with Dr. Cribier was brokered by Peter Block, MD, my mentor in the U.S. and also one of the grandfathers of structural heart disease in the United States. Dr. Block was one of the early adapters of all structural procedures and one of the first to do balloon mitral valvuloplasty in an adult in the United States. Dr. Block and Dr. Cribier were longtime colleagues and friends from the balloon valvuloplasty days in the mid-to-late 1980s. As the fellow in France for the year, my role was mainly research and to learn procedures like valvuloplasty. For valve implants, I was the crimper, the person who crimps the valve onto the balloon, which was a good way to get familiar with the technology and get close to the table. 

It was Dr. Cribier’s influence that brought Emory the minimalist approach. All the cases we did early on in France, his valve implantation series from 2002-2004, were all done awake in the cath lab. Dr. Cribier’s vision is for TAVR to be a stent-like procedure, where people are checked in the day of their procedure, and among all the cases of the day, some people have a coronary stent, some have valvuloplasty, some have a TAVR performed, and all procedures are done serially awake in the cath lab without using much more resources than would be used for a coronary stent. This is the way Dr. Cribier saw it from the beginning, and he has made the most headway in this direction. 

Early in May 2012, we decided to try to adopt this minimalist approach in the United States, and we did a great deal of planning, along with in-servicing and teaching, in preparation. At that time, we had done thousands of balloon valvuloplasties with our very experienced cath lab team. We had done a few hundred TAVRs by May 2012, and had a great deal of experience with percutaneous access and percutaneous closure, which is important for transfemoral TAVR if you are going to do it awake. We also had to train our nursing staff to be able to take the minimalist approach patients to the floor. In the study, we only took a quarter of the patients undergoing the minimalist TAVR cath lab approach to the floor and some still went to the ICU. Right now, I can tell you 90% or more of our minimalist approach patients are going to the floor rather than the ICU. Basically, every cath lab TAVR patient goes to the floor unless they have experienced a problem or complication, or need to be monitored. The standard now is from the cath lab awake to the floor. We are currently doing 95-96% of all our transfemoral TAVRs awake in the cath lab. It’s become our go-to strategy, and it is not the exception. It is the new rule. 

Currently, with the smaller sheaths available, about 80% of our approach is transfemoral, and 20% is alternative access. As sheath sizes get even smaller, then the percentage of transfemoral access will go up, which is why this technique is so exciting, because we actually implemented it with the older, larger valve systems. For our study, we used the minimalist approach with a 22 and 24 French valve system. In Europe, they obviously went through that phase of 22 and 24 French, but are ahead of us by several years. When our study came out, we had just gotten approval to use a valve with a much lower profile delivery system. The next-generation valve systems are all much lower profile, making a TAVR procedure with percutaneous access and closure seem much more feasible. The smaller sheath sizes lift much of the intimidation of doing a TAVR percutaneously off of the operator. 

What have you found to be the advantages and disadvantages of using transthoracic versus transesophageal echo?

Usually when we have patients swallow the probe for long periods of time, the majority of operators will put the patients to sleep so that they are more comfortable. We do use transesophageal echo on awake patients all the time for diagnostic purposes. Let’s say someone comes to the hospital and has what we think is an infection on a heart valve. We administer conscious sedation, put the probe down, and take pictures. The procedure usually lasts 20 minutes, then the probe is pulled out and the patient tolerates it just fine. So for short procedures or diagnostic procedures, use of transesophageal echo is acceptable, but for a prolonged period of time in an awake patient, people are more concerned about having the probe down. Certainly it can be managed, but when you take an older person that has difficulty breathing, put them flat on the table, put the probe down, and your procedure goes over an hour, the patient is put at a disadvantage. If patients are under general anesthesia, then we will use transesophageal echo. With transthoracic echo, much of the time, the resolution is not as good because the probe is not as close to the heart as when you swallow it. However, if you have a good stenographers and good echocardiographers, they can make very comparable pictures. Our echo team has seen over 800 TAVR cases and they know details about using the transthoracic echo to help us determine where to place the valve, how much leak is left, and whether there is any damage or complications to the heart. Changing to transthoracic echo is an important piece of the minimalist approach: we don’t put the probe down so the patient can breathe easier, we don’t put a Foley catheter in their bladder, and the patient is awake. For elderly patients, if a probe is put down for a long periods of time with general anesthesia and a breathing tube, often these patients have trouble swallowing when they wake up, which may last for some time. For patients who have already had some problem beforehand, it seems to aggravate it further. With a lot of malnourished elderly patients, the use of transesophageal echo and general anesthesia definitely limited or prolonged the recovery from these procedures. With the minimalist approach, patients don’t go to sleep, they can eat one hour after the procedure, and they ambulate much quicker, because they are not connected to all these cords in the intensive care unit. We also don’t have any problems with urinary retention, particularly in the older men with big prostates, because we are not using Foley catheters. We return patients back to the state they were in very quickly. Another problem in the intensive care unit is all the bells going on all night long. People can’t get enough sleep and it aggravates delirium at night, particularly in the elderly patient. Our minimalist approach patients are sent to a private room with a family member, where they can get some sleep and recover. All these things translate to faster recovery, lower length of stay, less resource utilization, and our study showed the minimalist approach to be just as effective and just as safe as the standard approach. It is a win for all parties involved.

How does CT inform the transthoracic echo?

This touches on pre-procedure planning, which is an important aspect and one that has made the minimalist approach possible. Procedures are very directed and short. First, the CT scan tells us whether patients have reasonable transfemoral access, so we are not in the cath lab pushing in the legs and not being able to deliver the device because we didn’t plan accordingly. That wouldn’t go well in an awake or an anesthetized patient. Second, we know what size valve to pick from combinations — and I use this word deliberately — combinations of what we find on the CT scan, what we find on the ultrasound, and possibly using balloon sizing. We use multiple modalities to confirm very quickly what size valve we are going to use so the correct implant can be delivered quickly and start working right away, without leaks and without rupturing the aorta. The CT scan has been pivotal in the planning stage. It is not the only tool, but it has been one of the biggest contributions in the last 5 years to TAVR. There are other things we corroborate with the CT, but it has been a big jump forward. 

Dr. Thourani mentioned the CT scan can be sent to an outside company and if their reading conflicts with Emory’s sizing, at that point, you will use balloon sizing.

There are commercially available programs where you can send your CT scan to be read. I do think that there are some limitations to CT and there is some variability between the readers, and that is why we use at least two modalities. We need to measure these areas by two different approaches and make sure they agree before we settle on the valve size. CT with echo, CT with balloon sizing, balloon sizing with echo: we use at least two, sometimes three modalities. In other words, it is important to get information that agrees from multiple sources. If I measure by ultrasound, by CT, and by balloon, they should all agree. At least two of the three are the truth, in the end. If you hang your hat on only one modality, there is always a shortcoming, and that is why we double- and triple-check. The 30-day results of the minimalist group had no mortalities, and that’s just fantastic, right? But the reason why patients have good results is not just because they went through the cath lab. That is part of it, but it is also because the planning was done appropriately, and the nursing staff, cath lab staff, and operators were all trained appropriately. While I did the majority of minimalist cases in the beginning, everybody on the paper participated in doing these cases. Dr. Thourani, a surgeon, did some of the minimalist cath lab patients with excellent outcomes. The training and preparation were important, but the message is that this approach is simple overall.

You mentioned the low mortality in the minimalist approach patients at nearly one year. What were some of the other important outcomes measured and how did they compare to the standard approach?

One main difference was ICU stay, in number of hours. Even if a patient went to the ICU after a minimalist approach, the amount of time they stayed in the ICU was less. The overall number of people going to the ICU was less, while all of the standard approach went to the ICU. About 20% of our minimalist approach patients in the study went to the ICU from the cath lab and some of that is a result of a culture that is very common throughout the United States. There was no difference between the two procedures in stroke and transient ischemic attack (TIA), which is an important indicator relative to the location of the procedure, because people may think, well, maybe the Emory TAVR team is not as quick in the cath lab, because we didn’t have key support, and that would cause more problems. But stroke differences were similar. There is no difference in mortality at 30 days or our median follow-up at close to one year. It is no longer about 30-day outcomes anymore, even though a lot of the action does occur within 30 days. If enough morbidity is created in a patient early on, even if they don’t suffer mortality at 30 days, that morbidity, especially in an inoperable high-risk patient, will translate into mortality at longer-term follow-up. The financial and economic impact is also equally important, and the savings with the minimalist approach was about $10,000. Some of that was related to where the TAVR was done, because certain charges are associated with the cath lab and OR, but much of the cost difference was driven by length of stay. This is a big area that a lot of people are trying to improve upon. Cost is critically important in this day and age, and we are becoming more effective and efficient as a result. Our length of stay was shorter by two days with the minimalist approach. You can continue to shave off length of stay with a same-day admit. That would save more time, because the way our system is set up, we admitted the day before, so the patients were ready, then they would have their procedure on day 2, and discharge Monday on day 3 or 4. So further reductions are possible. I know John Webb is studying the minimalist approach to see if a next-day discharge is possible and safe. 

We have started doing same-day admits at Emory, which was not part of this analysis, but there are pathways, similar to what we do for pre-op or a pre-admit testing, where patients go see the anesthesiologist and get all their blood drawn the day before, and then they spend the night in a hotel and come in the next day. We definitely have moved towards this. The story continues to get more interesting, because a lot of hospital administrators have had trouble accepting some of the new technology coming through due to the fact that it has been very expensive. The average cost for the minimalist approach was about $44,000 and for standard approach, it was about $55,000. The cost of the valve is more than two-thirds of the overall cost of the procedure, so we really have to find ways to minimize cost. A minimalist approach can definitely translate and move forward in more centers. If centers have the experience to move to the minimalist strategy, it is just as safe and utilizes fewer resources, which then translates to cost savings.

What have you found from the “halo effect” of additional testing required for TAVR?

Additional testing can provide some source of revenue as long as patients are done as outpatients. If you treat them as inpatients, they get bundled into different DRGs and it doesn’t have the same effect. So if you do them as an outpatient, there is some benefit. There is also a halo effect from simply bringing patients into a hospital system. There is a benefit in that family members will also come, and come for things other than their aortic valve. So it does seem to provide a stream of new patients for hospital system. Whether small, medium or large, hospitals struggle with their volumes. I do think TAVR provides something. Certainly we do have to be able to stand on every piece. Whether it is an initial workup, a test, or a possible hospitalization, it all has to make sense for administration to support new technology in the United States. We have to find ways to make it appealing and make it work, so we can continue to learn about new ways to help our patients, and progress the field in this country and not only have it occur outside the United States. 

Any final thoughts?

I would like to give credit to Peter Block and Alan Cribier, who have forged the way and made our work possible. 

References

1. Wasek S. Interview with Babaliaros V. Transcatheter aortic valve replacement at the Emory Structural Heart Disease and Valve Center. Cath Lab Digest. 2012 Oct; 20(10): 1-12. 
2. Babaliaros V, Devireddy C, Lerakis S, Leonardi R, Iturra SA, Mavromatis K, Leshnower BG, Guyton RA, Kanitkar M, Keegan P, Simone A, Stewart JP, Ghasemzadeh N, Block P, Thourani VH. Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): outcomes and cost analysis. JACC Cardiovasc Interv. 2014 Aug; 7(8): 898-904.
3. Babaliaros VC, Junagadhwalla Z, Lerakis S, Thourani V, Liff D, Chen E, Vassiliades T, Chappell C, Gross N, Patel A, Howell S, Green JT, Veledar E, Guyton R, Block PC. Use of balloon aortic valvuloplasty to size the aortic annulus before implantation of a balloon-expandable transcatheter heart valve. JACC Cardiovasc Interv. 2010 Jan; 3(1): 114-118. doi: 10.1016/j.jcin.2009.09.017. 

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Overview 

This article will alert readers to the fact that a transfemoral TAVR can be performed with minimal morbidity and mortality, and equivalent effectiveness compared to the standard approach to performing transfemoral TAVR in a hybrid OR with accompanying general anesthesia and transesophageal echocardiography. This process is greatly improved when transfemoral TAVR is performed in a catheterization laboratory. This method offers lower resource use, shorter patient length of stay, and significantly lowers hospital costs. Transfemoral TAVR should be performed by a very experienced operator and team.

CEE CME/CEU Accreditation and Designation

The Center of Excellence in Education (CEE), is accredited by the Institute of Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.

The Center of Excellence in Education (CEE) designates this enduring activity for a maximum of ONE (1) AMA PRA Category 1 Credit (s)^™.      

This educational activity has been planned and implemented in accordance with the Institute for Medical Quality and the California Medical Association’s CME Accreditation Standards (IMQ/CMA).  

This module is additionally accredited for RNs and other licensed healthcare providers for ONE (1) CE by California Board of Registered Nursing and California EMT-P ~ Pre-Hospital Provider.

Documentation of awarded credit is provided for registered learners in exchange for completed post test and activity evaluations included in the modules.

Target Audience

This enduring article is designed for interventional cardiologists, radiologists, clinical cardiologists, vascular medicine specialists, cardiac and vascular surgeons, nurse practitioners, cath lab technologists, and other health care professionals with a special interest in the field of interventional and vascular medicine. 

Needs Statement

CEE reviews each activity for the current evidence-based science and our activities provide the latest best practices that physicians require to improve patient outcomes.

Activity Goals

The overall goal of this activity is to improve knowledge and competence by the target audience implementing a TAVR program whose ultimate goal is to improve patient care.

Desired goals and outcomes are evident when TAVR teams, at both levels, experienced and beginning, become aware of an end goal studied and accomplished by Emory University: once 200+ transfemoral TAVRs have been safely accomplished in a hybrid OR with good outcomes, these procedures can potentially translate into the cath lab, be performed less invasively, and use fewer resources. Very elderly TAVR patients are quickly returned to their original state post procedure, and often are able to be discharged 24 hours post procedure rather than up to 5 days post procedure.

Learning Objectives

Upon completion of this article, participants should be able to:

1. Define the minimalist approach to transfemoral TAVR and where it takes place.
2. Describe methods that can be used to achieve a minimalist approach transfemoral TAVR.
3. Describe the optimal collaborative and structural aspects of an established TAVR program.
4. Identify that the transfemoral TAVR minimalist approach is much easier on the elderly and there is the potential that the minimalist TAVR patient can be discharged 24 hours post procedure.

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A review has been conducted by the CEE CME Committee that includes evaluation of objectives, content, faculty qualifications, and commercial supporters (i.e. pharma companies, instrument or device manufacturers) to comply with, and ensure the Institute for Medical Quality (IMQ)/California Medical Association (CMA) and Accreditation Council for Continuing Medical Education (ACCME) standards are met.

In accordance with the standards of commercial support of the IMQ/CME and ACCME, all speakers are asked to disclose any real or apparent conflicts of interest, which may have a direct bearing on the subject matter they will be presenting in this article.

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Discussion of off-label product usage and/or off-label product use during live cases is made at the sole discretion of the faculty. Off-label product discussion and usage are not endorsed by The Center of Excellence in Education.

Authors, faculty and planners participating in continuing medical education activities sponsored by The Center of Excellence in Education are required to disclose to the activity audience any real or apparent conflicts of interest related to the content of their presentations. Faculty not complying with this policy are not permitted to participate in this activity.

Dr. Thourani disclosed commercial relationships as a grant/research support with Edward Lifesciences, St. Jude Medical, Medtronic, Abbott Medical, and Sorin Medical. No conflict of interest was identified.

Dr. Babaliaros disclosed commercial relationships as a consultant with Edward Lifesciences, Medtronic, and Boston Scientific. No conflict of interest was identified.

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This article is sponsored by The Center of Excellence In Education and the educational partner HMP Communications.

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This article is funded through an educational grant through a commercial supporter. The Center of Excellence in Education ensures that its activities are educational and meet the needs of the target audience.

This educational activity is developed without influence from commercial supporters.

This educational activity is supported by an educational grant from Edwards Lifesciences in accordance with industry standards.

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This article does not endorse any commercial products.  

CME Accreditation for this activity originated on October 15, 2014.

CME Accreditation for this activity expires on October 31, 2015.

In order to complete this educational activity, please visit the website to answer questions and obtain your certificate: https://www.cathlabdigest.com/TAVRMin

Check out the previous two article in Cath Lab Digest's TAVR CME/CEU series:

From November 2013: "Planning and Developing a Successful TAVR Program at Maine Medical Center: Economic, Program, and Procedural Considerations" 

From December 2013: "Focusing on Each Patient: TAVR Care Protocols at Long Island Jewish Medical Center"

From March 2014: "Adding Value with TAVR at the Oklahoma Heart Institute" 

From May 2014: "Reducing Length of Stay and Enhancing Clinical Outcomes for TAVR Patients with a Focused Clinical Pathway"