Progress in the field of cardiovascular medicine continues to advance at galloping speed. To catch up on the latest clinical trial data and expert opinions, over 30,000 healthcare professionals from 174 countries gathered for the European Society of Cardiology Congress in Barcelona on 26–29 of August 2022.¹ We at AS&K had the pleasure of joining the Congress virtually, to monitor innovation in healthcare and keep our perspectives fresh. From all the interesting advancements revealed at ESC, ranging from an optimized pharmacological approach to manage decongestion,² to the adoption of a polypill for post-myocardial infarction secondary care,³ we chose to look back on the evolution of a pivotal heart procedure and to look forward to the promise of AI. 

In the journey for optimal evidence-based patient care, innovations such as transcatheter aortic valve implantation (TAVI) represent a true leap forward. It is amazing how this field has developed since we first started working in it, back in the early 2010s.  

Up until 2002, the only available intervention for a calcified aortic valve (aortic stenosis, AS) was surgical aortic valve replacement (SAVR), which involves removing the defective valve and replacing it with a mechanical or biological prosthesis. In the much less invasive TAVI procedure, an expandable bioprosthetic valve is guided to the heart via a catheter originating most commonly in the femoral artery, and is placed within the native valve, taking over its duties without removal of native tissue.  

In celebration of the 20 years since the first ever proof-in-human TAVI, pioneering doctors Alain Cribier and Hélène Eltchaninoff moderated a session on the past and future of the procedure. During the past two decades, over 9,000 patients have been enrolled in TAVI trials, generating a wealth of evidence that turned a previously considered odds-defying intervention into a standard-of-care therapy for AS. 

Innovation in TAVI continues today, with new generation balloon-expandable and self-expandable bioprosthetic aortic valve technology becoming even safer.^4,5 The implantation procedure itself is also evolving, with ongoing optimization of resources. Patients may now undergo conscious sedation rather than general anesthesia for a “minimalist” TAVI, increasing the rates of same-day or next-day discharge.⁶ Also on the horizon is the customary use of cardioembolic protection systems consisting of small filters placed within blood vessels during TAVI, which catch debris and thus reduce the risk of stroke.^7,8  

In 2019, the FDA approved the expansion of the TAVI indication to patients with AS at low risk for surgery.⁹ This lowered the age of the TAVI beneficiary, as will the anticipated indications for TAVI in patients with bicuspid aortic valve, the most common congenital heart defect, and for “pre-emptive” TAVI for patients with asymptomatic severe AS or moderate AS associated with heart failure.¹⁰  

As the estimated durability of bioprosthetic valves is approximately 10 years, patients will soon routinely outlive their substitute valves. To this end, valve-in-valve implantations are being explored, with a focus on strategies that prevent blockade of coronary arteries during these procedures.¹¹ Will valve-in-valve practices continue to evolve to accommodate multiple reinterventions, or are these a short-term remedy until we find a long-term solution? Time will tell. 

Innovations in the digital transformation of healthcare were also featured at ESC, expanding on the potential for technology to improve HCP training, diagnostics, and bring meaningful change to clinical decision-making. In the future, the technological arsenal of a cardiologist may include virtual reality-based platforms to improve pre-operative planning,¹² and even the use of everyday smartphones to detect treatment-relevant atrial fibrillation.^13,14 AI-based tools may also be routinely employed to detect AS from routine echocardiograms,¹⁵ or in many more creative ways. 

Do these advancements evoke a futuristic scenario of AI-complemented medicine, where doctors input clinical data and quickly receive a reliable and reproducible output of detailed mechanism of disease, patient prognosis and response to treatment? Or a future of de-skilling, loss of clarity, empathy and human autonomy? Are you for or against AI changing the practice of cardiology? 

This was the subject of ‘Great debate’ at ESC. In these sessions, speakers put forward opposing arguments, regardless of their personal stance in a format designed to challenge mindsets. As session moderator Prof. Martin Cowie commented, “It’s really good to have someone who’s seen as a proponent for AI to argue against it and vice-versa”. Would you agree with Professor Alan Fraser that ‘artificial intelligence’ is a misnomer, as AI is simply a use for statistics, a tool to which we are not typically opposed? Or would you agree with Professor Partho Sengupta, that since AI lacks human common sense, it will always have an unreliable performance at the point of care? 

We can often only speculate on the impact of today's innovation and health technology on tomorrow's outcomes. Had the pioneers of TAVI dreamed of conscious sedation and cardioembolic protection systems 20 years ago? Likewise, we can only theorize as we accompany the modernization of cardiology practice. 

At AS&K, we’ve been at the cutting edge of developments in the field of cardiology for over 25 years. This has given us the opportunity to witness the excitement engendered by the arrival of new therapies, the challenge of learning the associated science, and the privilege of working with many of the leading experts driving this field forwards. Contact Alejandro Potes for a consultation at alejandro.potes@asandk.com today.
 

References

1. ESC press release: Best of ESC Congress 2022. Available from: https://www.escardio.org/The-ESC/Press-Office/Press-releases/Best-of-ESC-Congress-2022. Accessed September 2022. 
2. Mullens W, et al. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload [published online ahead of print, 2022 Aug 27]. N Engl J Med. 2022;10.1056/NEJMoa2203094. 
3. Castellano JM, et al. Polypill Strategy in Secondary Cardiovascular Prevention [published online ahead of print, 2022 Aug 26]. N Engl J Med. 2022;10.1056/NEJMoa2208275. 
4. Giordano A, et al. Comparative one-month safety and effectiveness of five leading new-generation devices for transcatheter aortic valve implantation. Sci Rep 2019;9:17098. 
5. Abdel-Wahab M, et al. Comparison of balloon-expandable vs self-expandable valves in patients undergoing transcatheter aortic valve replacement: the CHOICE randomized clinical trial. JAMA. 2014;311:1503–14. 
6. Harjai KJ, et al. Efficiency, Safety, and Quality of Life After Transcatheter Aortic Valve Implantation Performed With Moderate Sedation Versus General Anesthesia. Am J Cardiol 2020;125:1088–95. 
7. Stroke PROTECTion With SEntinel During Transcatheter Aortic Valve Replacement (PROTECTED TAVR). Available from: https://clinicaltrials.gov/ct2/show/NCT04149535. Accessed September 2022. 
8. British Heart Foundation Randomised Trial of Routine Cerebral Embolic Protection in Transcatheter Aortic Valve Implantation (BHF PROTECT-TAVI). Available from: http://www.isrctn.com/ISRCTN16665769. Accessed September 2022. 
9. ACC News Story: FDA Expands TAVR Indication to Low-Risk Patients. Available from: https://www.acc.org/latest-in-cardiology/articles/2019/08/16/13/49/fda-expands-tavr-indication-to-low-risk-patients. Accessed September 2022. 
10. Rahhab Z, et al. Expanding the indications for transcatheter aortic valve implantation. Nat Rev Cardiol 2020;17:75–84.  
11. Annibali G, et al. Valve-in-valve transcatheter aortic valve replacement: the challenge of the next future. Mini-invasive Surg 2022;6:12. 
12. Abjigitova D, et al. Virtual Reality in the Preoperative Planning of Adult Aortic Surgery: A Feasibility Study. J Cardiovasc Dev Dis 2022;18:9–31.  
13. Freyer L, et al. Rationale and design of a digital trial using smartphones to detect subclinical atrial fibrillation in a population at risk: The eHealth-based bavarian alternative detection of Atrial Fibrillation (eBRAVE-AF) trial. Am Heart J 2021;241:26–34. 
14. ESC press release: Atrial fibrillation screening using smartphones increases detection and treatment. Available from:  https://www.escardio.org/The-ESC/Press-Office/Press-releases/Atrial-fibrillation-screening-using-smartphones-increases-detection-and-treatment. Accessed September 2022. 
15. ESC press release: Artificial intelligence identifies severe aortic stenosis from routine echocardiograms. Available from: https://www.escardio.org/The-ESC/Press-Office/Press-releases/Artificial-intelligence-identifies-severe-aortic-stenosis-from-routine-echocardiograms. Accessed September 2022.