Debate over transcatheter aortic valve replacement (TAVR) procedures continues as the Centers for Medicare and Medicaid Services (CMS) considers changing the status quo. Are TAVR volume requirements limiting rural and minority access to this life-saving procedure, or are they still necessary for patient safety?
In June 2018, cardiology news sources widely reported that CMS opened public comment on established volume requirements for hospitals and heart teams to perform TAVR. The Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) then met on July 25 to discuss the issue. A report in Cardiovascular Business suggested that the committee appeared split on the subject—especially in weighing the potential harms of limiting TAVR to only high volume hospitals.
The Case for TAVR Volume Requirements
For those on the side of maintaining TAVR volume requirements, the benefits are obvious—volume is associated with positive outcomes and lower rates of complications. In fact, a 2018 expert consensus document from four major cardiology societies actually supported increasing volume requirements to maintain a TAVR program, to ensure adequate data collection for statistically reliable quality metrics and quality assurance.
A common problem in elderly men, obstructive uropathy, can look a lot like heart failure.
When pulmonary edema is present, heart failure is often the "scapegoat" says Melissa Walton-Shirley, MD in a commentary on Medscape. Approaching heart failure with "an air of skepticism" might help.
I've seen a handful of obstructive uropathy cases masquerading as heart failure in elderly men in recent years. I shudder to think how many times I've missed it. I suspect that it's not just men who suffer. Some of our female patients with "diastolic dysfunction" and overflow incontinence seem to suffer from backpressure that finds its way into the pulmonary vasculature.
This video from Diagnostic and Interventional Cardiology's Pulse TV shares the biggest piece of news from the American College of Cardiology's annual conference last month---that Transcatheter Aortic Valve Replacement (TAVR) out-performed surgical valve replacement in the PARTNER II trial.