Can you tell us about your role as a TVT program director?

A number of program directors help to guide the entire meeting, from the development of different sessions to determining how TVT can continue to evolve. As the program directors, we divide into areas because it is hard for one person to cover every single area. Some of us will cover TAVR, some mitral, some tricuspid, and some left atrial appendage (LAA) occlusion, and we develop sessions in discussions with faculty. We are catering to a changing landscape, both from the point of view of the devices and how they change, clinical data and how it is integrated into our practice, and also in how we continue to train new structural interventionists in this field. The way we trained 10 years ago is very different from the way we need to train now, because the needs are different, the expectations are different, the patients are different, and the technologies are different. It is a constantly changing landscape. We want the right faculty to be in each session and are balancing expertise and seniority with bringing up younger and junior faculty. It is also important to ensure diversity. We don't want these meetings to feature the same people over and over again. We need to mentor and grow young faculty, and ensure that there is sufficient diversity of sex and race in every session. For example, there is no reason for there not to be a female interventionist in every session, because there are so many amazing female interventionists out there.

What are some of the open TAVR questions under discussion?

The biggest topic is the lifetime management of patients with aortic stenosis. Which valve do you choose in a younger patient with a longer life expectancy? We will look at what the data say about how long that valve will last. TVT will have several sessions on valve selection and valve durability. New data are coming out on some of the valves regarding 5-year durability, so there will be discussion about these longer term data in terms of durability and hemodynamics. We know TAVR is not a class effect; it does matter which valve you put into certain patients. We will address those subgroups of patients where valve selection is important, including patients with small annuli, many of whom are women. We will also address bicuspid valves, a challenging subgroup of patients where in some situations one valve may offer a different outcome than another. Then, what do we do when the valve does fail? If we decide that that the first valve is a surgical valve, what do you do when that surgical valve fails? If you decide that first valve is a TAVR valve, what do you do when that valve fails? Will we place another TAVR valve? Will there be surgery to remove the TAVR valve? We will be addressing these important questions.

How are physicians focusing their practice on structural heart disease treatment?

It is definitely changing. If I look at my own journey as an interventionist, I trained solely in coronary intervention, and then structural became available and I started learning how to do that. For a long time, my practice involved doing both types of procedures, but over the last few years, my focus has become more and more structural, for a few reasons. One is that the number of patients is growing rapidly. In my practice, the structural volume is increasing by 20% to 30% annually, whereas the coronary volume remains static, and, if anything, is experiencing a small decline. Since structural volumes are increasing, I've had to dedicate more time, but also the complexities are increasing. It is becoming harder to do as a part-time job, so to speak, because there are so many new procedures to learn. Forget about mitral and tricuspid, which take the TAVR complexity level up another 10 times. If you want to also do mitral and tricuspid procedures, there isn't enough time in the day to dedicate yourself to learning everything necessary. Just considering TAVR, there continue to be new procedures and challenges, such as when we treat a failing valve, do we need to cut the leaflets in order to be able to maintain coronary access? Or what should we do when we can't perform the procedure from a transfemoral access? It has become harder and harder to say, "I'm a complex PCI operator and I'm a TAVR operator." More and more, people will have to dedicate themselves to structural heart and it will become a full-time job. Even within structural heart, we are going to see some subspecialties, although some people will continue to do all of structural heart. In large academic hospitals, I think we will see an evolution where certain operators do TAVR and then some operators focus on mitral and tricuspid therapies, because there are so many new therapies, it is hard to learn and be good at all of them.

What are some of the other TAVR-related topics under discussion at TVT?

In addition to all the questions centered around lifetime management, we will also be addressing the emergence of new valves. The anticipated FDA approval in the next year or two in the United States means there will be more than just two valves on the market for TAVR. For a long time, the Sapien valve (Edwards Lifesciences) and the Evolut valve (Medtronic) have been the only options. We now have the Navitor valve (Abbott Vascular) approved for extreme high-risk patients. This year or the next, we also will see the Acurate valve (Boston Scientific) approved. We will be covering a lot of the technicalities around these new valves because we want our colleagues to become familiar with them and the idea that we will be moving from 2 choices to 4 possible choices of a valve to implant.

There are additional areas where we still figuring out how to optimize outcomes for TAVR, including rates of pacemaker implantation and whether cerebral embolic protection devices are necessary to prevent stroke. TVT will have a large session on protection, which is still a current and important topic. Another important topic is coronary access, as part of the concept of lifetime management of the aortic stenosis patient. How do we access the coronary arteries in the future once patients have had a TAVR valve placed?

The final area under discussion for TAVR will be the use of TAVR for aortic regurgitation. Up to this point, we have only used TAVR for the treatment of aortic stenosis, but there is a valve for aortic regurgitation that is approved in Europe, and the first study has been completed here in the United States. Aortic regurgitation remains an unmet clinical need. We may see that valve and one other valve become available for clinical use in the next year.

What can attendees look forward to in terms of the variety of educational formats at TVT?

TVT will offer lots of case-based sessions, which we have found to be a good path for learning about complex patient scenarios and complications. We also created something new, the iCOACH EC track, which involves hands-on training, including around imaging, such as how to use computed tomography scans to predict or help with different challenges in the procedure. TVT is more than just a conference; it is also a course. The difference is subtle. Courses are more hands-on and offer more training, allowing you to come back with practical knowledge for direct use in your practice, whereas a conference may be more about presenting data, and TVT will offer both.

Live cases will also be a central feature of TVT. Some cases will be live and others are recorded live because certain procedures are more complex and can't be done in 45 minutes. Why try and push operators to do it in a short time? Let them do the procedure, take the time necessary, and then show the case in a timeframe where the audience can get the most out of that knowledge and teaching. The case theater will be streaming live cases for the entire 3 days of the conference, all of which are moderated.

Is there something that you personally are looking forward to at the meeting?

I am looking forward to the live cases because I really enjoy them. Montefiore Medical Center is one of the live case sites and we are very excited. We will be showing some interesting cases in mitral and tricuspid valves that have never been shown before at a conference. These cases will demonstrate how the field of structural intervention is growing and how we are pushing the boundaries.

Find more: 
TVT Newsroom (With a Special Focus on TAVR)