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Vol. 73. Issue 5.
Pages 431-432 (May 2020)
Vol. 73. Issue 5.
Pages 431-432 (May 2020)
Letter to the Editor
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Scientific evidence and expert opinion. Why is TAVI different?
Evidencia científica y opinión de expertos. ¿Por qué el TAVI es diferente?
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Íñigo Lozanoa,
Corresponding author
inigo.lozano@gmail.com

Corresponding author:
, Beatriz Vaquerizob, José Ramón Rumorosoc, Moshen Mohandesd
a Servicio de Cardiología, Hospital de Cabueñes, Gijón, Asturias, Spain
b Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
c Servicio de Cardiología, Hospital de Galdakao, Galdakao, Vizcaya, Spain
d Servicio de Cardiología, Hospital Universitario Joan XXIII, Tarragona, Spain
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Pilar Jiménez Quevedo, Manuel Pan, Raúl Moreno, Armando Pérez de Prado
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To the Editor,

We read the article by Jiménez Quevedo et al.1 on the disparity between scientific evidence and expert opinion regarding the need for on-site cardiac surgery in centers performing transcatheter aortic valve implantation (TAVI), and we would like to thank the working group for underscoring the importance of scientific data in this debate.

The situation in Spain is worthy of analysis, not only for the strikingly diverse initial interpretations of the need for cardiac surgery in these centers, but also for the continuous inconsistencies in relation to this issue. Some examples include ceasing the activity in Andalusia, Catalonia, and Castile and León without having analyzed the outcomes, which in the end, turned out to be very good,2 maintaining the activity in Castile-La Mancha and Madrid, and later, resuming the activity in Andalusia. To further complicate things, the future suppression of a cardiac surgery service in Basque Country in a center where TAVI is performed will make this situation even more convoluted. Although a part of this haphazardness can be due to fragmentation of the health system, there are other origins.

Up to now, the reasons given have been the potential to resolve complications by having on-site cardiac surgery, and in the recent refusal to reopen 2 centers in Catalonia, not the protection afforded by surgery, but the argument that treatment decisions should be made by a cardiology team.

If there is one specialty that can boast of scientific evidence, it is cardiology. We have very robust data in this line from the AQUA registry of 17 979 patients,3 which shows no significant differences in mortality rates between centers with and without on-site surgery. These results were confirmed in 1822 cases in Austria and 384 procedures in Spain.2 Furthermore, in one registry in Europe4 with 27 760 patients and another in the United States5 with 47 546 patients, urgent conversion to surgery was required in 0.76% and 1.17% of the total, respectively, with decreasing values over the years. Moreover, many of these procedures were carried out using outmoded techniques, and in both registries half of the small number of patients who required surgery did not survive hospitalization.

The argument about the desirability of decision-making by the cardiology team is very appropriate, but medical-surgical sessions have been conducted in centers without on-site surgery for years, either face-to-face or using one of the many currently available options that do not require personal contact. That said, the recommendation should also be for ischemic heart disease, and therefore, should be implemented in centers where it is not being done.6

We would like to point out the importance of the consequences of the present situation. First, it limits patients’ access to treatment, with the subsequent increase in mortality.7 Second, the Spanish Society of Cardiology should be aware that the professional development of many interventional cardiologists and that of our cardiology services is limited. Advanced imaging is not progressing, and private funding for computed tomography facilities is decreasing, which is crucial given the limited access of cardiology patients to this resource. This has led to the flight of solidly trained professionals to other centers. Third, the Spanish Society of Cardiology should determine whether it is realistic to face the huge demand only with cardiac surgery in the centers, and if this is not possible, it should foresee what scenario will cover this demand, because ultimately, it may not have to completely depend on cardiology.

There is a strong, traditional link between cardiology decisions and clinical evidence, which in this case, endorses TAVI in centers without on-site surgery. Hence, as the working group indicates,1 these procedures should be allowed in nonsurgical centers that have experienced interventional cardiology and vascular teams using repositionable self-expanding valves in high-risk patients.

References
[1]
P. Jiménez Quevedo, M. Pan, R. Moreno, A. Pérez de Prado.
Scientific evidence versus expert opinion. Should we modify clinical practice guidelines?.
Rev Esp Cardiol., 73 (2020), pp. 187-189
[2]
J. Roa Garrido, J. Jimenez Mazuecos, A. Sigismondi, et al.
Transfemoral TAVR at hospitals without on-site cardiac surgery department in Spain: a multicenter registry.
JACC Cardiovasc Interv., 12 (2019), pp. 896-898
[3]
H. Eggebrecht, M. Bestehorn, M. Haude, et al.
Outcomes of transfemoral transcatheter aortic valve implantation at hospitals with and without on-site cardiac surgery department: insights from the prospective German aortic valve replacement quality assurance registry (AQUA) in 17 919 patients.
Eur Heart J., 37 (2016), pp. 2240-2248
[4]
H. Eggebrecht, B. Vaquerizo, C. Moris, et al.
Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI).
Eur Heart J., 39 (2018), pp. 676-684
[5]
A.M. Pineda, J.K. Harrison, N.S. Kleiman, et al.
Incidence and outcomes of surgical bailout during TAVR: insights from the STS/ACC TVT Registry.
JACC Cardiovasc Interv., 12 (2019), pp. 1751-1764
[6]
A.B. Cid Álvarez, O. Rodríguez Leor, R. Moreno, A. Pérez de Prado.
Registro Español de Hemodinámica y Cardiología Intervencionista. XXVIII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2018).
Rev Esp Cardiol., 72 (2019), pp. 1043-1053
[7]
G. Elbaz-Greener, S. Masih, J. Fang, et al.
Temporal trends and clinical consequences of wait times for transcatheter aortic valve replacement.
Circulation., 138 (2018), pp. 483-493
Copyright © 2019. Sociedad Española de Cardiología
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