Lessons from the learning curve.

Transcatheter aortic valve insertion (TAVI) has taken center stage, but TAVI is not easy to do, has limitations, and is a complex procedure requiring multiple operators. Thus, interventional cardiologists, cardiac surgeons, echocardiographers, anesthesiologists, and vascular surgeons have formed “teams” that come together to work in hybrid operating rooms or catheterization laboratories to perform TAVI in what have been selected investigational centers in the United States. Published results of the first U.S. trial and, of course, multiple reports from European centers, which have had the opportunity of using TAVI for far longer, have uniformly supported the notion that TAVI is successful therapy for selected patients. But there is no free lunch—TAVI has associated risks of stroke, vascular complications, heart block, and so on. So, the questions are “How difficult is TAVI really?”; “How does experience with TAVI influence risk?”; and “With experience, does TAVI become ‘easy’ enough so that it can be performed by large numbers of practitioners?” In short, “What is the learning curve for this procedure?”