**5. The concept of heart team in TAVI procedure**

Because of the old age of patients and high-risk factors, TAVI procedure is still relatively risky and difficult, so it is necessary to make a variety of emergency plans during the operation, including the most dangerous emergency such as heart rupture and arrest. Compared with coronary stent intervention, the probability of conversion to emergency surgery is similar, but the harm of TAVI is much higher. The risk of emergency during coronary stent was 0.2%, and the mortality rate was 1%. However, the data of 27,760 TAVI patients enrolled in 79 European centers in 2017 showed that the probability of emergency surgery was 0.76% [50]. The 3-day, perioperative, and 1-year mortality rates were 34.6%, 46%, and 78%, respectively. The average age of patients who needed emergency heart surgery was 82.4 years old, and 67.5% of the patients were female with Logistic EuroSCORE score of 17.1% and STS score of 5.8%. The analysis showed that the incidence of emergency heart surgery during TAVI decreased from 1.07% in 2013 to 0.70% in 2014 and has remained stable since then. It implies the clinical experience play important role in the procedure.

The most common causes of emergency cardiac surgery during TAVI are left ventricular perforation (28.3%) and annular rupture (21.2%) caused by guide wire. The mortality rate of patients in this situation was as high as 34.6% within 72 hours after operation. The total in-hospital mortality rate of these patients was 46.0%, and the mortality rate of patients with valvular annulus rupture was the highest (62%). The analysis also showed that the independent predictors of in-hospital death after emergency cardiac surgery were age > 85 years (OR = 1.87, P = 0.044), valvular annulus rupture (OR = 1.96, P = 0.060), and immediate emergency cardiac surgery (OR = 3.12, P = 0.037). Of these patients undergoing emergency

**91**

just stand by.

*Transcatheter Treatment of Aortic Stenosis and Regurgitation*

cardiac surgery, 114 survived during hospitalization, with a 1-year survival rate of

It should be emphasized that complications of TAVI are usually more critical, faster, and more difficult to predict. In particular, TAVI indication will soon be extended to low-risk patients, to ensure the safety of these patients is more important at this time. The cooperation of multiple heart teams can better ensure the

Perhaps the greatest contribution of TAVI technology to medical treatment is not the techniques itself or clinical effect, but a unique medical cultural phenomenon. For the first time, barriers between medical disciplines have been replaced by multidisciplinary collaboration to deal with a state of disease. As Cribier pointed out in his review of the 20th anniversary of TAVI procedure [8], the development of TAVI technology has for the first time created a model of collaboration among cardiac doctors. It is difficult for cardiologists or surgeons alone to complete all the links involved in TAVI surgery, but the two can complement each other and provide safer and effective treatment for these high-risk and elderly patients. Therefore, in many countries and regions in Europe and the United States, only TAVI cases that have been signed by the heart team can be reimbursed by the medical insurance. According to the 2012 European Society of Cardiology/European Society of Cardio-Thoracic Surgery (ESC/EACTS) guidelines for the management of cardiac valvular disease, TAVI can be considered for high-risk patients with symptomatic severe aortic valve stenosis, but requires a "heart team" comprehensive analysis and evaluation (II/B) [51]. The newly released American Heart Association/American College of Cardiology (AHA/ACC) guidelines on valvular heart disease in 2017 also give the highest level of recommendation on the importance of heart teams during

The American Society of Thoracic Surgeons (AATS), in conjunction with the American College of Cardiology, the Society of Cardiovascular Angiography and Intervention, and the College of Thoracic Surgeons (STS), released the latest edition of 2018 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement [53]. The new consensus points out that in order to ensure the safety and effectiveness, TAVI procedures should be performed in centers that meet the following criteria. At least 50 TAVI cases (or 100 in 2 years) and at least 30 surgical aortic valve replacements (or 60 in 2 years) are performed in the hospital each year. The standards also include various medical quality requirements for morbidity, mortality, and quality of life within a limited time, as well as conducting quality assessment/improvement plans. The consensus also points out that TAVI operators, as members of a multidisciplinary team, should have participated in at least 100 cases of transfemoral TAVI in their career, of which at least 50 were primary operations. Surgeons on the TAVI team should have performed at least 100 surgical aortic valve replacements in their careers or at least 20 (or 50 in 2 years) in the year before the start of the TAVI program. In Chinese experts consensus about the heart team construction [44], it implies that the surgeon in TAVI team should have valve surgery experience more than 15 years and perform aortic valve surgery at least 25 cases a year. In addition, surgeons should actively participate in the TAVI procedure like wire and valve manipulation and not only

Carl Tommaso, one of the co-chairs of the expert consensus committee, commented that the TAVI procedure safety evaluation will be used to define centers whether this operation can be performed safely or not. In the past 6 years, more and more centers have performed TAVI, and the indications are being extended to surgical low-risk elderly patients, so it is time to redefine TAVI recommendations.

*DOI: http://dx.doi.org/10.5772/intechopen.92997*

only 40.4%.

safety of patients.

TAVI procedure [52].

*Advances in Complex Valvular Disease*

area was larger (2.3 cm<sup>2</sup>

the new device utilization rate increases.

aortic valve disease, TAVI always can be done.

The TAVI group had lower all-cause mortality and incidence of disabled infarction (but not statistically significant) (2.9% vs. 4.6%), significantly reduced crippling infarction (0.8% vs. 2.4%), and significantly reduced hospitalization for heart failure (3.2%vs. 6.5%). In addition, in the TAVI group, the transvalvular pressure difference was lower (8.6 mmHg vs. 11.2 mmHg), and the effective valve orifice

of perivalvular regurgitation after TAVI, only 22% of the patients received the third-generation valve. The new valve increases the edge of the skirt to reduce perivalvular leakage, so it is expected that the regurgitation rate will decrease as

At present, there are about 60,000 TAVI operations in the United States every year. This may increase to 75,000 if patients at moderate risk received TAVI and to 100,000 or more if extended to low risk. The ultimate goal of TAVI surgery is that TAVI can be performed in all comers. It means no matter what the risk, no matter what the anatomy, and even what age; as long as it is the need for intervention of

The two studies of PARTNER III and EVOLUT in 2019 are an eye-catching new research progress of TAVI technology. On this basis, the FDA and the European Drug Regulatory Agency have approved the extension of TAVI surgical indications from surgical high-risk patients with severe aortic stenosis to surgical low-risk patients, which indicates that TAVI technology will continue to develop rapidly towards the goal of the whole population in the future. It is believed that more research evidence will be published one after another, the guidelines for the diagnosis and treatment of cardiac valvular disease will change greatly, and interventional

Because of the old age of patients and high-risk factors, TAVI procedure is still relatively risky and difficult, so it is necessary to make a variety of emergency plans during the operation, including the most dangerous emergency such as heart rupture and arrest. Compared with coronary stent intervention, the probability of conversion to emergency surgery is similar, but the harm of TAVI is much higher. The risk of emergency during coronary stent was 0.2%, and the mortality rate was 1%. However, the data of 27,760 TAVI patients enrolled in 79 European centers in 2017 showed that the probability of emergency surgery was 0.76% [50]. The 3-day, perioperative, and 1-year mortality rates were 34.6%, 46%, and 78%, respectively. The average age of patients who needed emergency heart surgery was 82.4 years old, and 67.5% of the patients were female with Logistic EuroSCORE score of 17.1% and STS score of 5.8%. The analysis showed that the incidence of emergency heart surgery during TAVI decreased from 1.07% in 2013 to 0.70% in 2014 and has remained stable since then. It implies the clinical experience play important role in

The most common causes of emergency cardiac surgery during TAVI are left ventricular perforation (28.3%) and annular rupture (21.2%) caused by guide wire. The mortality rate of patients in this situation was as high as 34.6% within 72 hours after operation. The total in-hospital mortality rate of these patients was 46.0%, and the mortality rate of patients with valvular annulus rupture was the highest (62%). The analysis also showed that the independent predictors of in-hospital death after emergency cardiac surgery were age > 85 years (OR = 1.87, P = 0.044), valvular annulus rupture (OR = 1.96, P = 0.060), and immediate emergency cardiac surgery (OR = 3.12, P = 0.037). Of these patients undergoing emergency

) at 12 months. Despite the high proportion

vs. 2.0 cm<sup>2</sup>

valvular technology will play a more and more important role.

**5. The concept of heart team in TAVI procedure**

**90**

the procedure.

cardiac surgery, 114 survived during hospitalization, with a 1-year survival rate of only 40.4%.

It should be emphasized that complications of TAVI are usually more critical, faster, and more difficult to predict. In particular, TAVI indication will soon be extended to low-risk patients, to ensure the safety of these patients is more important at this time. The cooperation of multiple heart teams can better ensure the safety of patients.

Perhaps the greatest contribution of TAVI technology to medical treatment is not the techniques itself or clinical effect, but a unique medical cultural phenomenon. For the first time, barriers between medical disciplines have been replaced by multidisciplinary collaboration to deal with a state of disease. As Cribier pointed out in his review of the 20th anniversary of TAVI procedure [8], the development of TAVI technology has for the first time created a model of collaboration among cardiac doctors. It is difficult for cardiologists or surgeons alone to complete all the links involved in TAVI surgery, but the two can complement each other and provide safer and effective treatment for these high-risk and elderly patients. Therefore, in many countries and regions in Europe and the United States, only TAVI cases that have been signed by the heart team can be reimbursed by the medical insurance. According to the 2012 European Society of Cardiology/European Society of Cardio-Thoracic Surgery (ESC/EACTS) guidelines for the management of cardiac valvular disease, TAVI can be considered for high-risk patients with symptomatic severe aortic valve stenosis, but requires a "heart team" comprehensive analysis and evaluation (II/B) [51]. The newly released American Heart Association/American College of Cardiology (AHA/ACC) guidelines on valvular heart disease in 2017 also give the highest level of recommendation on the importance of heart teams during TAVI procedure [52].

The American Society of Thoracic Surgeons (AATS), in conjunction with the American College of Cardiology, the Society of Cardiovascular Angiography and Intervention, and the College of Thoracic Surgeons (STS), released the latest edition of 2018 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement [53]. The new consensus points out that in order to ensure the safety and effectiveness, TAVI procedures should be performed in centers that meet the following criteria. At least 50 TAVI cases (or 100 in 2 years) and at least 30 surgical aortic valve replacements (or 60 in 2 years) are performed in the hospital each year. The standards also include various medical quality requirements for morbidity, mortality, and quality of life within a limited time, as well as conducting quality assessment/improvement plans. The consensus also points out that TAVI operators, as members of a multidisciplinary team, should have participated in at least 100 cases of transfemoral TAVI in their career, of which at least 50 were primary operations. Surgeons on the TAVI team should have performed at least 100 surgical aortic valve replacements in their careers or at least 20 (or 50 in 2 years) in the year before the start of the TAVI program. In Chinese experts consensus about the heart team construction [44], it implies that the surgeon in TAVI team should have valve surgery experience more than 15 years and perform aortic valve surgery at least 25 cases a year. In addition, surgeons should actively participate in the TAVI procedure like wire and valve manipulation and not only just stand by.

Carl Tommaso, one of the co-chairs of the expert consensus committee, commented that the TAVI procedure safety evaluation will be used to define centers whether this operation can be performed safely or not. In the past 6 years, more and more centers have performed TAVI, and the indications are being extended to surgical low-risk elderly patients, so it is time to redefine TAVI recommendations.

Some studies have shown that there are fewer postoperative adverse events in hospitals that perform more TAVI operations, and the accumulated TAVI experience is related to the improvement of postoperative outcomes. In 2018, the *Journal of the American Medical Association Cardiology* (JAMA Cardiol) published an observational cohort study [54] that included 60,538 TAVI operations performed in 438 hospitals from 2011 to 2016, with an average age of 82.3 years. Hospitals with a high amount of surgical valve replacement (annual average ≥ 97 / year) are more likely to start TAVI in the early stage, and the amount of TAVI increases faster with time. The average TAVI cases of hospitals with high surgical valve replacement volume to those with low volume was 32 vs. 19 in the first year, 48 vs. 28 in the second year, 82 vs. 38 in the third year, and 118 vs. 54 in the fourth year (P < 0.001). Combined with the analysis of hospital TAVI and surgical valve replacement volume, the 30-day mortality rate in high TAVI volume hospital was lower. When the hospital also has a high volume of surgical valve replacement, the effect is more obvious. Patients with high surgical valve replacement volume and high TAVI volume had the lowest 30-day mortality (for hospitals with low surgical valve replacement volume and TAVI volume: OR = 0.77; 95%CI, 0.66–0.89). Hospitals with both high volume of surgical valve replacement and TAVI cases may have the best outcome, which confirms the importance of hospital clinic experience.
