Editor：Cheng Zhan
Interventional therapy has become the most important development direction of structural heart disease. Transcatheter valve therapy has led the fourth revolution in interventional cardiology. This journal specially invited Professor David Scott Lim of the University of Virginia Medical Center to conduct an in-depth discussion on "Interventional Therapy of Heart Valve Disease".
International Circulation: We have achieved rapid developments in the field of interventional therapy of Valvular Heart Disease in recent years. Would you please share with us about the development status of TAVR in the United States? For low-risk patients,which one is better, TAVR or SAVR?
David Scott Lim: The transcatheter aortic valve replacement (TAVR) has really revolutionized the approach to aortic valve disease. It was studied in the original PARTNER trials, as well as then subsequently for other valves. Those TAVR trials were looking at a balloon-expanded valve to be delivered. It was subsequently studied with a self-expanding valve, like the CoreValve, as well. Each device, as it has gone through the regulatory process, has walked down the risk status. So, at first it was studied in prohibitive risk, then high risk, then intermediate risk.
Recently, in the PARTNER 3 trial or the CoreValve Low-Risk trial, studied in patients with low surgical risk. It was randomized between a surgical standard of care (surgical aortic valve replacement) and TAVR. They were two relatively large trials, and they demonstrate equivalence and in some cases, superiority, of the TAVR approach. It is certainly a less invasive approach.
There are still some outstanding questions regarding durability, because the lower risk patients are usually younger patients, who will likely require longer term durability. Ultimately, until the question of whether TAVR equates to a 15-18-year freedom from reintervention similar to a SAVR approach, only then will we have a final answer to this.
International Circulation:What do you think are the major challenges that we are facing in the interventional therapy of valvular heart disease?
David Scott Lim: Generally speaking, interventional therapy is safer. It is less invasive being percutaneous, and so forth, therefore conveying a greater degree of safety, which is offset, in most cases, early on in the development of the therapy by a lesser degree of efficacy compared to a more invasive surgical approach. Having said that, certain therapies such as the approach to coronary artery disease have become very mature with time, and we have been able to more clearly define its optimal efficacy in addition to its safety in certain patient subgroups. So I would say that the approach to coronary artery disease has become quite well established with the appropriate patient selection, with other approaches to other types of heart disease, such as valve disease or even more recently, to heart failure, being less well determined, and we are still being a little more cautious until we can grow the field to maturity in determining optimal patient selection.
International Circulation: How do you think about profound influences of “2020 ACC/AHA Guideline for the management of patients with Valvular Heart Disease” in clinical practice?
David Scott Lim: We owe a debt of gratitude to our colleagues who have created these heart valve guidelines, because often the guidelines that are put out really have significant impacts on clinical practice. I would say to an increasing degree, my colleagues around the world in cardiovascular disease look to those guidelines to help us figure out what is the appropriate therapy when sitting one-to-one with a patient and a patient’s family, trying to figure out if they have aortic valve disease, mitral or tricuspid valve disease or pulmonary valve disease, what the right therapy to offer and the right steps to take to evaluate the patient. We keep coming back to that on a regular basis. Those guidelines are quite detailed, and as you go through them. I think that there is a nice balance that the writing committee took in terms at looking at how much data we have for the given issues and trying to provide a reasonable approach to the management of the disease processes.
International Circulation: Looking forward, how do you think about the most promising research direction in the field of interventional therapy of Valvular Heart Disease? What cooperation and exploration do you think can United States and China do?
David Scott Lim: Most recently, I would say one of the largest, most impactful studies has been on the transcatheter treatment of functional mitral regurgitation (functional being secondary to underlying ventricular cardiomyopathy). With the COAPT trial, and even looking at the COAPT trial in the context of the MITRA-FR trial to better understand which therapies or which patients with functional mitral regurgitation would be benefited from TEER (transcatheter edge-to-edge repair) therapy, I think that has really shifted the communities perception of what we can accomplish and what we should accomplish in patients with functional MR, and really emphasized the importance of guideline-directed heart failure therapies as an important predicate for considering TEER.
Then, I think looking to the future, the next question is what is the value of complete elimination of the mitral regurgitation in functional MR, compared to a repair therapy, which often times significantly decreases the degree of functional MR, as opposed to transcatheter mitral valve replacement (TMVR) where you completely eliminate it. There will be a different balance in terms of risk, as the transcatheter mitral valve replacement systems are larger, and sometimes have to be delivered transapically rather than transfemorally. So all of that is a balance, and hopefully with some of the more recent TMVR trials, we are going to be able to answer that question - the value of the increased risks and increased complexity of systems versus the value of complete elimination of MR.
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