There's no denying that TAVR will kill open AVR volumes in the near future....Is this being implemented in the CT surgery training curriculums to an extent that the current new grads can perform TAVRs (I mean actually being the one who performs the procedure and not just stand next to the interventional cardiologist.....)? Even if so, will cardiologists even give the CT guys a shot at doing them with referrals or have the CT guys already missed the wagon this time around as well like they did with PCIs?
Wire skills for current/future CT surgeons?
- Thread starter axfem
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The case requires ct surgery to be involved in the OR during the surgery. It's not going to be like pci.
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My CT surgery residency friends say they are definitely learning the perc valve stuff and that they aren't giving it away this time. Sounds like a lesson learned.
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This may be true now, at least in the US, but will not be true forever. When it comes to endovascular tech, it is getting smaller and smaller all the time. You also have the advent of the transcaval approach. We do more TAVRs than anyone in the US and our CT surgeons don't do a ton anymore. They are always in the room, but the biggest surgical issue now is access site issues, which they call us for anyways. My suspicion is that in the coming years, they will likely require a CT surgeon on standby, but unless it is an unusual case, not more. There are limits to how small they can make their sheaths, but looking at our TEVAR sizes, it is ridiculous how small they have gotten them.
Take it from someone in another integrated program in a field that is heavily endo oriented, great that you have dedicated cath lab time. Realize that for most people, that is not going to be enough. The basic endo skills are not particularly challenging, several months is a reasonable orientation, but you need continuous exposure to be able to perform these procedures. It isn't about physical skills. It is about imaging, case planning, etc. I am hopeful that most training programs will try to get their i6 resident this, but I certainly wouldn't depend on cardiologists to invest in CT surgeons learning the nuances and frankly, that is what most programs are going to do.
They won't have much of a choice in this. CT surgery absolutely needs to be loud and proud on this to make sure that they stay involved, for the sake of CT surgery and patients. But, ultimately, they have little power. The referral base, even in academics is controlled by cardiology. CT surgery (like vascular) is tiny compared to cardiology. When you talk about power on a regulatory and government level, unless cardiologists are maiming people left and right (which they aren't), it will never be a CT primary procedure.
The reality is that most cardiologists do not want to do TAVRs. Unlike PCI it requires a rather large team/organization to build a functional and good TAVR program. On the other hand, as you point out, the referral base is cardiology. It remains to be seen how involved CT surgery will be in TAVR going forward. Only time will tell. i6 programs in general are fairly progressive and will attempt to train their residents. But, unless there is a significant shift in how things are done (at least in this locale), they will learn by standing beside a cardiologist doing the bulk of the procedure.
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If you look at Europe, CT surgeons say they are being squeezed out by cardiologists. The question is, as TAVRs get more and more routine and less and less complex, how will CT surgery play a role. Awake TAVIs are now the norm, sheath sizes are getting smaller and in 10 or so years, government or hospital isn't going to want to pay for 2 interventionalists, a surgeon and a cardiac anesthetist + a ton of nurses to be in the room.
The whole concept of heart team was originally because the procedure was new with more complications, now that the procedure is becoming less surgery and more percutaneous with less complications, cardiologists I believe can easily argue that the procedure itself would be better done by someone who does angiograms and PCI on a regular basis vs someone who does open surgery. Throw in the fact that cardiology controls the referral base, i'm not exactly sure how CT surgery can make a case for their continued involvement beyond being in the room or being on call for complications.
The next space is Mitral. Mitraclip is firmly interventional, the question is now what about TMVR. I could see surgeons playing a larger role in TMVR but again the same thing could happen to TMVR like TAVI and at that point cardiac surgery volumes will be cut in half and their only bread and butter case will be CABGs.
