Gone are the days of SAVR? Future of cardiac anesthesia?

[hununuh]

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FDA Approves TAVR for Low-risk Patients Creates A Paradigm Shift in Cardiology

August 16, 2019 — In one coordinated move, the U.S. Food and Drug Administration (FDA) opened use of transcatheter aortic valve replacement (TAVR) to low-risk patients today. The FDA simultaneously expanded the indications for use for both the Edwards Lifesciences’ Sapien 3 valve and Medtronic’s...

www.dicardiology.com

TAVR is now approved for low risk patients too. As cardiac procedures continue to advance, would the demand for cardiac anesthesiolgist decline?

 

[thinkorswim]

The obvious answer is yes. And as the cardiologists continue to push for performing TAVRs like a routine cath, as they already do in Europe, there will be no need for a CT surgeon or anesthesiologist to be present at all.

In my opinion, the only way for cardiac anesthesiologists to survive is to prove their worth in the cath lab as primary echocardiographers for other structural interventions (MitraClips and the emerging tricuspid interventions). As it stands, when you bring in an additional cardiologist to do the imaging, they are either highly subsidized by the hospital or losing money from not being in clinic. It's just cheaper for us to do it in the long run.

 

[dchz]

The obvious answer is yes. And as the cardiologists continue to push for performing TAVRs like a routine cath, as they already do in Europe, there will be no need for a CT surgeon or anesthesiologist to be present at all.

In my opinion, the only way for cardiac anesthesiologists to survive is to prove their worth in the cath lab as primary echocardiographers for other structural interventions (MitraClips and the emerging tricuspid interventions). As it stands, when you bring in an additional cardiologist to do the imaging, they are either highly subsidized by the hospital or losing money from not being in clinic. It's just cheaper for us to do it in the long run.

Totally agree. It's not really that difficult to throw on a gown and pair of gloves to put a Phased array transducer on the pt's chest and look at the leak... I'm surprised we didn't do this in the first place.

Also to those that didn't know. Not all cardiologists are certified in echo or even know how to do an TTE well... years of relying on paid techs makes their skills minimal.

But once the reimbursement goes up, is it not cheaper if the cardiologists just do the TTE themselves?

 

[T-burglar]

There’s still lots of cardiac surgery going on. As TAVR becomes a no-anesthesia case in your hospital 3 more structural interventions that require consultant level TEE will take its place. ACTA is only going away in your hospital if you let it.

 

[T-burglar]

Totally agree. It's not really that difficult to throw on a gown and pair of gloves to put a Phased array transducer on the pt's chest and look at the leak... I'm surprised we didn't do this in the first place.

Also to those that didn't know. Not all cardiologists are certified in echo or even know how to do an TTE well... years of relying on paid techs makes their skills minimal.

But once the reimbursement goes up, is it not cheaper if the cardiologists just do the TTE themselves?

In our shop if the TAVR is minimalist then we just have either our CTA guys or a Sonographer get the TTE shots. We only do it if the sonographer is out of the room and busy. Either way it’s not inconveniencing a second cardiologist.

 

[ryanjmy]

They’ll still need us. Pts frequently get unstable when you shove a large cather across a valve with an area of 0.5. Also vascular complications and bleeding is not uncommon. A cardiologist isn’t going to want to manage that on his own.

Isolated savr are not a significant number of our cases. It’s more common to do an avr/cabg. What does this mean for AS with single vessel disease? Stent/TAVR vs surgery?

 

[AdmiralChz]

Anyone who’s been paying attention has seen this coming for at least 4-5 years with the progressive success of TAVR. That being said, SAVR won’t go away especially in cases of concomitant CAD where valve/CABG is necessitated. I definitely think open straightforward SAVRs will decline and that’s not such a bad thing if the long-term outcomes for TAVR holdup.

CT Surgery is already being pushed more into the realm of sick patients - think your low EF emergent bypasses, MCS, transplant at select centers. Several community hospitals are scaling back or closing down CTS programs (one of our sites essentially has already) in favor of clustering that care at a regional heart center.

As for CT Anesthesia, they’ll be fine. Their demand is artificially increased now as many (most?) shops won’t credential or hire you for advanced TEE work without a fellowship. There are places that do low and moderate risk TAVR without anesthesia presence and I’d suspect this to increase. For higher risk folks we’ll still need to be there.

But once the reimbursement goes up, is it not cheaper if the cardiologists just do the TTE themselves?

I’ve said this before - follow the money. Our country is scaling back / holding things steady with reimbursement I see no impetus or urgency outside of the egg heads at ASE to increase echo reimbursement. If it does happen (very unlikely unless it’s pared with a decrease in procedural reimbursement), you’ll see Cardiologists step up immediately to capture that money particularly if it threatens their bottom line.

The job market is super saturated for general Cardiologists (just ask any new fellowship grad) and even for subspecialists really. An increase in TEE guidance reimbursement would open up avenues for more folks to get hired. Right now the pay is awful considering the expertise required. For now the economics favor keeping Cards in clinic/reading room but if that changes don’t expect them to passively just let ACTA folks get the cash. Just look at how they’ve managed to totally push aside the true big fish in medicine, CT surgery, in the past 30 years.

 

[caligas]

any time there is one of these questions, just ask “what’s the cheapest option” and thats what we will be doing in 10 years.

 

[kjamess]

The job market is super saturated for general Cardiologists (just ask any new fellowship grad)

absolutely false. its easily the best job market for all cardiologists.

 

[ProRealDoc]

CT anesthesiologists can also do general/regional. I don't see a scenario where one would be unemployed unless they absolutely refuse to work.

 

[Mikkel]

any time there is one of these questions, just ask “what’s the cheapest option” and thats what we will be doing in 10 years.

The other thing to ask:

"Mr Patient, do you want open surgery with long recovery or minimally invasive procedure with short recovery?"

"Gee, let me think..."

 

[Ronin786]

Anyone who’s been paying attention has seen this coming for at least 4-5 years with the progressive success of TAVR. That being said, SAVR won’t go away especially in cases of concomitant CAD where valve/CABG is necessitated. I definitely think open straightforward SAVRs will decline and that’s not such a bad thing if the long-term outcomes for TAVR holdup.

CT Surgery is already being pushed more into the realm of sick patients - think your low EF emergent bypasses, MCS, transplant at select centers. Several community hospitals are scaling back or closing down CTS programs (one of our sites essentially has already) in favor of clustering that care at a regional heart center.

As for CT Anesthesia, they’ll be fine. Their demand is artificially increased now as many (most?) shops won’t credential or hire you for advanced TEE work without a fellowship. There are places that do low and moderate risk TAVR without anesthesia presence and I’d suspect this to increase. For higher risk folks we’ll still need to be there.



I’ve said this before - follow the money. Our country is scaling back / holding things steady with reimbursement I see no impetus or urgency outside of the egg heads at ASE to increase echo reimbursement. If it does happen (very unlikely unless it’s pared with a decrease in procedural reimbursement), you’ll see Cardiologists step up immediately to capture that money particularly if it threatens their bottom line.

The job market is super saturated for general Cardiologists (just ask any new fellowship grad) and even for subspecialists really. An increase in TEE guidance reimbursement would open up avenues for more folks to get hired. Right now the pay is awful considering the expertise required. For now the economics favor keeping Cards in clinic/reading room but if that changes don’t expect them to passively just let ACTA folks get the cash. Just look at how they’ve managed to totally push aside the true big fish in medicine, CT surgery, in the past 30 years.

People also forget just how many cardiologists exist in this country. It's the second largest specialty behind general IM. They've got the numbers to push into whatever realm they can justify.

 

[deleted697535]

Are you guys high!?!
Of course demand wont decline. Demand cant decline. People are always always always getting older and sicker whether it be the pregnant lady with a tight mitral, a fontan that grows old or even a failed tavi. Our work doesn't decrease it just becomes more specialized, more acute.


As our outcomes become better we just find a new subset of sick people to operate on that previously we wouldn't touch.
Dont worry, were good. More than good

Plus just like evars I think the long term data will tell the true tail of these tavis will be after 1 to 3 years. We might just end up investigating these patients up the wazoo for leaks etc forever. If I was 55 and had an infrarenal aaa I'd probably have an open repair done now. Maybe the long term data for tavis will be the same

 

[deleted875186]

Are you guys high!?!
Of course demand wont decline. Demand cant decline. People are always always always getting older and sicker whether it be the pregnant lady with a tight mitral, a fontan that grows old or even a failed tavi. Our work doesn't decrease it just becomes more specialized, more acute.


As our outcomes become better we just find a new subset of sick people to operate on that previously we wouldn't touch.
Dont worry, were good. More than good

Plus just like evars I think the long term data will tell the true tail of these tavis will be after 1 to 3 years. We might just end up investigating these patients up the wazoo for leaks etc forever. If I was 55 and had an infrarenal aaa I'd probably have an open repair done now. Maybe the long term data for tavis will be the same

Very true, although I can’t imagine TAVR outcomes at long term follow up will be significantly worse than surgical valves.

 

[deleted875186]

Are you guys high!?!
Of course demand wont decline. Demand cant decline. People are always always always getting older and sicker whether it be the pregnant lady with a tight mitral, a fontan that grows old or even a failed tavi. Our work doesn't decrease it just becomes more specialized, more acute.


As our outcomes become better we just find a new subset of sick people to operate on that previously we wouldn't touch.
Dont worry, were good. More than good

Plus just like evars I think the long term data will tell the true tail of these tavis will be after 1 to 3 years. We might just end up investigating these patients up the wazoo for leaks etc forever. If I was 55 and had an infrarenal aaa I'd probably have an open repair done now. Maybe the long term data for tavis will be the same

I would also disagree with a few points. Seems like the cardiac trained people are being pushed to do more and more non cardiac procedures on previously sick cardiac patients, many of which seem like they could be done easily by a General anesthesiologist. I think it’s naove to say that te cardiac trained folks will just care for sicker and sicker patients.

 

[deleted171991]

Are you guys high!?!
Of course demand wont decline. Demand cant decline. People are always always always getting older and sicker whether it be the pregnant lady with a tight mitral, a fontan that grows old or even a failed tavi. Our work doesn't decrease it just becomes more specialized, more acute.


As our outcomes become better we just find a new subset of sick people to operate on that previously we wouldn't touch.
Dont worry, were good. More than good

Plus just like evars I think the long term data will tell the true tail of these tavis will be after 1 to 3 years. We might just end up investigating these patients up the wazoo for leaks etc forever. If I was 55 and had an infrarenal aaa I'd probably have an open repair done now. Maybe the long term data for tavis will be the same

I think you are the one who's high. As specialization happens, physicians are more easily replaceable with "specialized" midlevels. Monkey see, monkey do, follow the protocol. The number of cases truly needing a highly-educated anesthesiologist is decreasing every year, while the number of graduating suckers is going up.

Yes, they will always need firefighters for the pregnant lady with Fontan, for the 400 lb-ers etc., while supervising 4+ rooms every day. Who the heck, in his/her right mind, wants a job like that?

I guess there is a sucker born every minute. Make hay...

 

[deleted697535]

Lol you

I think you are the one who's high. As specialization happens, physicians are more easily replaceable with "specialized" midlevels. Monkey see, monkey do, follow the protocol. The number of cases truly needing a highly-educated anesthesiologist is decreasing every year, while the number of graduating suckers is going up.

Yes, they will always need firefighters for the pregnant lady with Fontan, for the 400 lb-ers etc., while supervising 4+ rooms every day. Who the heck, in his/her right mind, wants a job like that?

I guess there is a sucker born every minute. Make hay...

Lol I agree!
Maybe there is and I probably am 1.

But no one outside of your country supervises more than 2 rooms! And only your country equates nurses with doc's!

So I'm good with being a sucker doing all my own cases forever lol

 

[deleted697535]

I would also disagree with a few points. Seems like the cardiac trained people are being pushed to do more and more non cardiac procedures on previously sick cardiac patients, many of which seem like they could be done easily by a General anesthesiologist. I think it’s naove to say that te cardiac trained folks will just care for sicker and sicker patients.

Yes I agree, it is naieve. And my post was written in haste. There still loads of people who cant have pci so theres still plenty of straight up cabg to go around.

But I also see a lot of my general colleagues who wont touch anyone with even a slight cardiac issue noted on their preop note. They would lose their mind if they had to take a vad for something simple. Its overwhelming for them.
But that's also good for us!

 

[Modanq]

I think that CT anesthesia still has lots of space to work in. It's in my opinion cardiac plus ICU are the few saving graces in anesthesiology. Mitral clips, watchman, structural, ep, and the cardiac OR, or what's left of it, but also CCU and CTICU with acute device management. For now we can make that space ours but requires years of relationship building and social capital/acceptance to play on the same team as the cardiologists across the country. This has to be a national effort. CT surgery had no alternative reference points so they were ok with anesthesia placing the lines, swans, art lines, TEE probes and now some places ecmo. For CT to stay alive we need to keep doing what we do to preping the pts in the cath lab, lines, swans, ice, and tee. And then let the proceduralists do their thing. It's a huge pie we just need to carve it out.