Transcatheter aortic valve implantation applications in Turkey; the role of the heart team approach.

Severe calcific aortic stenosis (AS) is the most common valvular disease in older population, which affects 2-7% of the population over the age of 65 years. In Turkey, the total population is 72.5 million and 7% of them were over 65 years of age according to official data (TUIK) in 2010. Surgery is still a gold standard approach, but surgical risk rises with age and the mean STS (Society of Thoracic Surgeons) score is approximately 15% in older age groups due to severe comorbidities leading to denial of surgery in 30-40% of these patients (1). Transcatheter aortic valve implantation (TAVI) is a novel technique, initiated by Alain Cribier in 2002 (2). So far, two available systems, Edwards SAPIEN (Edwards Life Sciences, Irvine, CA, USA) (Fig. 1) and Corevalve ReValving System (Medronic Inc, Minneapolis, MN, USA) have been widely used in Europe and USA. TAVI procedure is not only a novel interventional therapy, but also an excellent example for a hybrid procedure, which is successfully being performed with collaboration of cardiovascular surgeons and cardiologists. From 2002 to 2012, besides the experience gained, improvements in devices and technique resulted in an increase in procedural success rate from 75% to 98.5%. TAVI procedure was started in Turkey in early 2009 (3), and then followed by another center with a procedural success reaching up to 100% (4). These first two attempts were followed by other private and public training and research hospitals. In 2010, Turkish Ministry of Health finally began to support TAVI procedure in a particular group of training hospitals with a special budget making a pivotal financial plan. After the initial success rate and experience, Turkish Ministry of Health has decided to generalize TAVI to whole country by selecting university hospitals, which may be capable to do this procedure in 2011. Within the framework of this plan, TAVI procedure was began in Erzurum in November 2011 and will start in Trabzon in January 2012. So far, TAVI procedure was performed totally in 116 cases; 8 in 2009, 28 in 2010 and 80 cases in 2011, and continues to advance rapidly. One must be very careful and retain the property of acting ethically, because the excitement created by the interventional therapy may increase the unethical behaviors that had been experienced in the early period of widespread use of drug eluting stents. On the other hand, operator training is a crucial component of TAVI procedure, and it is also essential for the candidate center to have experience on coronary, endovascular and structural heart interventions; sufficient infrastructure (hybrid operation theater), and surgical support. The cost is important issue for national economy in our country, so the candidates for TAVI should be carefully selected among high-risk patients refused by surgeon to operate, because TAVI still has many life-threatening complications (5) and high stroke rate. Finally, in November 2011 the US Food and Drug Administration has approved the TAVI for inoperable AS, the Sapien (Edwards-Life sciences). TAVI is a promising intervention and will probably be offered to a wider group of patients in the future. However, the heart team consisting of surgeons and cardiologists must be fully aware of the clinical concept and rationality of TAVI bearing the economic reality of Turkey in mind. We must not be hasty and impatient to perform TAVI in an unrealistically liberal way. A national health policy must be established with collaboration of Turkish Cardiovascular Societies and Ministry of Health. New technologies and interventions must inevitably and constantly be brought to clinical practice by experienced training centers with a team approach.