The Transcatheter Aortic Valve Replacement Program at Mission Health

Dana Triplett, RN, can be contacted Dana.Triplett@msj.org. Dr. Mark Groh can be contacted at mgroh@ashevilleheart.com. Dr. Joshua Leitner can be contacted at Joshua.Leitner@msj.org.

I. Dana Triplett, RN, Coordinator Structural Heart/Valve Program Mission Health

Can you give us an overview of the transcatheter aortic valve replacement (TAVR) program at Mission Health?

Our TAVR program began in the fall of 2011. We knew the technology was coming, and in preparation, we started by looking at who the patients were in our region. The vetting process for our patients is quite an undertaking in many aspects. We also focused on pulling the team together, figuring out the different disciplines that would need to be involved. It includes everyone from cardiac surgery, interventional cardiology, and computed tomography (CT) to echo, and cath lab and nursing staff, so we started to build the team to look at our expected TAVR patients. Once our team was in place, we started to look at creating protocols and order sets. My biggest area of responsibility as the coordinator involves communicating with and educating patients about TAVR, and the process that entails.

Mission Health has been performing TAVR for about 2½ years now, and we have completed about 83 procedures. Our outcomes have been very good, and we have learned a great deal along the way.

As I noted, the testing process for our patients, the vetting to see if they are going to be a TAVR candidate, can be a process in and of itself. A key thing is educating the patients and family about the disease process and why the testing is important, to make sure we get the optimal treatment option for them.

How did you create protocols at the start of the program? 

We started early with TAVR as a commercial site, so it was challenging, as you can imagine, to come up with protocols that weren’t readily available. We gathered different team members together, including our echo specialist, and pulled what we could from research trials. We developed specific protocols with the teams that would be responsible for instituting them. It has been a very collaborative effort across disciplines. Our protocols have changed over time and still continue to change, as technology develops and as new devices come along. We are constantly trying to look at our processes, and improve and adapt our workflow so that it will be better for patient outcomes.

Was the hybrid OR already in place or was that something new built for the program?

It was new when we started our program, but our hybrid room was built with all expected technology advances in mind, including specialty imaging. TAVRs are one of the primary procedures done in the hybrid room. We do work with vascular as well, and they will do endovascular and some open hearts that require special imaging in that room.

Can you describe your patient population and geographic area?

Asheville, North Carolina is a beautiful setting and many residents end up retiring here. We have an older population here in the mountains, and have a lot of Medicare patients. As you know, aortic stenosis affects the older population, because of the disease process itself. We are very fortunate that we have such a strong cardiac service line at Mission Health, in all aspects. All these things put together make our area ideal for a TAVR program. 

Asheville Cardiology Associates is a large cardiology practice here in Asheville that the majority of patients utilize. We have one cardiovascular surgical group, Asheville Heart. Having these two main practices that our patients funnel through, and we working closely with them. In addition, our nursing staff is superb. They are dedicated, compassionate, and want the best outcomes for their patients. 

Can you talk more about your role as coordinator and some of the challenges you face?

When it comes to patient education, the biggest thing is trying to manage expectations. TAVR is for our older population, and as we age, there are more issues we encounter. We focus on making sure patients know we can fix their heart valve and make things better from a cardiac standpoint, but that co-morbid conditions also play a role in overall health. We try to manage the expectations of the patient and family, and the recovery process, because even though this is a less invasive procedure than an open heart, it still is a procedure where patients undergo general anesthesia. 

Do you typically get patients where their co-morbidities are under control or are you trying to manage on all fronts?

It can be both. Sometimes folks get tired of going to the doctor! Some issues may not have been well managed or it has been a while since the patient has seen their pulmonologist or their renal specialist. The process is pulling all those individuals in and making sure that everyone is on the same page with what we are looking at doing. We want as much information as possible about how the treatment plan is going to impact that body system in order to make sure that the patient is appropriately managed. Whether they have seen the doctor lately or not, it is crucial that the coordinator and the team communicate with all the specialists who are involved with the patient.

Once a patient enters the process for screening, how often are you talking with the patient and their family?

I feel like we communicate a lot. When the referral comes, we call the patient and explain what the valve clinic is and what the disease process is like. We then mail them information with an educational component as well. When patients come in for testing, we do more education. The valve clinic also offers the chance for more education. 

We talk with the families and the patients very frequently. That is one thing our patients and families like about the valve clinic and the nurse navigator roles, because they can call us directly and speak to us on the phone. We get to know our patients very well, their circumstances and their social network. It helps when you are looking at a procedure such as this, because to make sure that our patients are comfortable, we want to know everything necessary to properly take care of them.

As the coordinator, do you direct all the specialists involved, to make sure they are communicating with each other?

Absolutely. Communication is huge. TAVR is one of the forefronts of this type of collaborative effort. We have cardiothoracic surgeons, cardiologists, and all sorts of specialists in imaging all talking about one patient, and determining the best treatment plan for them. It happens a lot in oncology and other fields, but it is good to see it happening in another specialty area. I think this type of collaboration plays a huge role in making sure we are doing what is right for the patient. 

What is the organizing structure that helps with collaboration at your facility?

At Mission Health, we have a multidisciplinary clinic, where we review patients in the queue, discuss their case and all the different imaging, and the system issues going on, whether pulmonary or kidney. We often communicate what the patient is being evaluated for with the specialists’ offices. If the patient hasn’t seen that specialist in a while, we will have them go to that specialist and will ask for an update or for a particular test to be redone. Often we will consult with the specialist when the patient is going in the hospital, so that they can round on the patient and help to manage those disease processes. After the procedure, we like to be in close touch with the referring physician, whether it is the cardiologist or the primary care physician. We make sure the referring physicians know that their patient had a TAVR, that he or she was discharged on this day, and we provide a list of medications and the plans for follow-up. So we manage post procedure as well.

Do you have particular days of the week reserved for TAVR cases?

Yes, that has been one of our challenges. Not only is it a hybrid room, but it is a hybrid team. We have members from the OR and the cath lab, and multiple physicians that are involved in the procedures, so in order to coordinate these, it has been essential to have one dedicated day to make sure that we have the staff in place to do the procedure effectively. We typically do ours on Wednesday. If we have some patients that are inpatient and are more urgent, we do add on as needed for their care. 

What software do you use to track patients through the process?

We have an Excel database spreadsheet, and track things like where they are coming in, the date of referral, how long they are in our system, and how long it takes for us to give them a treatment option. We track a lot of our outcomes through our systems. It includes all the different physicians involved in the patient’s care, when we communicate with them, and how and what we communicate. 

Is the testing typically done within the Mission Heart system?

It varies, depending on the test. Certain tests like CT, which we rely on heavily for the sizing and placement of the valve, we like to do in our system, because there are certain protocols that we like to utilize. However, because we serve such a large regional area of western North Carolina, if there are things patients can have done at their local provider, by all means it is better for the patient, and it is better for the local provider, because it doesn’t take the financial impact away from their community. 

Have you begun to consider earlier ambulation for patients?

Yes, we are reconsidering all of our post procedure order sets. We are not only looking at the impact, but also anything else that may affect patient length of stay, and trying to expedite and optimize how long patients are in bed, how long they have central lines, and how long they have medication. Everything that would delay the rehabilitation process, we are looking to try to minimize. 

At the beginning, we tried to marry our cath lab order sets with our surgical order sets. With cath lab order sets, the patient is up and ambulating a lot sooner than they are in surgery, so taking that hybrid approach helped at the beginning. Our patients recover in the cardiovascular recovery area, so it’s a different population and a different expectation. It has taken time to look at these patients a little differently than we would the normal surgical patient.

What do you see as the primary keys to the success of your TAVR program?

Pulling your team together and making sure that your team members have the same goal in mind. We have been very fortunate. Everyone has wanted this program to succeed. A big thing is making sure that your administration is vested and supportive. Reimbursement has yet to really catch up with the time and energy and resources that are invested in these very complex patients, so to have administration push and support programs like this, that are very new as far as technology, and just out of the gate from research – it is essential for a program to succeed. Also, communication and the multidisciplinary approach. It’s refreshing to see physicians from different specialty areas communicate and have the patient at the center. The goal is to make sure we are doing what is necessary for that specific patient. Communication and the multidisciplinary approach have been very big factors in our success.

What are some of the things you’ve had to tweak over time?

I have tweaked everything! We have adjusted order sets and our process flow, particularly in the pre procedure phase, trying to streamline the process of getting the patient through the workup phase in an appropriate, safe, and timely manner in order to get them to the right treatment option. That can be challenging. Our patients have physical challenges, transportation challenges, time challenges, and often our patients have children caregivers who are working and have children of their own. Trying to coordinate everything to be a smooth process, and one that is as least stressful as possible for the patient and their family, has been a challenge on all fronts, but that’s what we do here at the clinic, and what we’ll keep striving to do, making sure that the process is as smooth as possible.

Any final thoughts?

The best part of my job is the patients. It is such an intense relationship, because all the people involved spend so much time with them. Perhaps it is also the generation of patients we are working with. They are forever grateful, even just for the little things, such as being able to call and get a direct answer. We walk patients through the process, and in a sense, they become extended family for us. 

II. Mark A. Groh, MD, Asheville Heart Associates, a Mission Health affiliate

Can you share your involvement with the TAVR program at Mission Heart?

I am a cardiac surgeon. I have been involved with the program since its inception. I was fortunate to have some close affiliations with members of the PARTNER trial, and I learned a fair amount from some of the trial sites that were very successful, helping to lay the groundwork for our program here.

We started our buildup with a shared clinic and the construction of a new clinic space within the hospital itself, because of the need to establish concierge-level care for our patients. They have special needs and we felt that a dedicated place within the hospital would be most beneficial. The valve clinic is a place we use every week to see patients, both in pre- and post-op follow-up, for evaluation. We have a space that offers a real physical presence for the surgeon and the cardiologist, in conjunction with the other members of the team. Echocardiographers, as well as the valve clinic coordinator and the navigators, also meet and see the patients in the valve clinic. 

We actually started doing cases in February 2012, but started work on the program about a year and a half before. During that time, we had to build a hybrid room, get the clinic space built, and get resources allocated so the people who needed to be there could be there. Karen Lemieux, Mission Heart’s Vice President of Heart Services, was incredibly supportive and helpful in making that happen. We had a three-person team: cardiologist Dr. William Abernethy, Karen, and myself, and we worked to get all of the obstructions to this kind of program out of the way, and to keep pushing the envelope to make sure that we could build a program that the hospital, the clinicians, and the region could be proud of.

How did you address the formation of care protocols?

We did look to surgery, and modified our order sheets appropriately. Our cardiovascular surgery program already had a fair amount of experience with small-incision heart surgery, and some aspects involved things like fast-tracking patients, so it has been part of the culture here for a while. We have some innovative nurses in the cardiovascular intensive care unit and in our step-down units who, along with our valve coordinator, helped standardize post-op care. We felt that our TAVR patients would be best taken care of on our surgical service, because our surgical presence is constant, and we have the same extenders and surgeons seeing post-op patients daily. All TAVR patients are admitted through the surgery service, undergo their procedure, and as they are cared for in the perioperative period, the first calls go to the surgery side. That standardization has been a little easier, because there are only two clinicians on the cardiology side who perform TAVR, out of 30-plus cardiologists, so whether a cardiologist who does TAVR will be available on weekends and holidays is not completely reliable. It gives us a little more redundancy and reliability in taking care of these patients.

As a surgeon, what do you feel are the strengths that you bring to the multidisciplinary team?

Having a large and significant vascular experience was very helpful in the beginning and we did not have any significant vascular complications, nor have we. We have since moved to alternative access and are doing more technically challenging cases. About a year and a half ago, we started doing alternative access through the transaortic route and the transinnominate route. Advantages include the short distance to deployment and the reliability of deployment in that position, as well as the lower paravalvular leak rate. That exposure, of course, is something that, as cardiac surgeons, we do every day. Creating a small, upper sternal incision, maybe 2-3 cm on the bone, and exposing that portion of the aorta, has been something where we’ve done in 35 or 40 cases now, and it is right up our avenue. 

Could you share more about the advantages of transaortic access?

The pain post procedure is exceedingly low, because 7/8ths of the sternum is not violated. We don’t even J the incision off. We just make a small upper sternotomy, maybe to the manubrium/sternal junction, but generally not that far. Certain patients are approached through the small second interspace mini thoracotomy. We use imaging to help determine the best access incision. We have used the transaortic approach in over half the cases we have done, particularly our reoperative cases, those patients who’ve had prior coronary artery bypass graft surgery, or valve replacement or valve-in-valve. The advantage over transapical is that you are not violating the heart muscle. Putting things into the apex of the heart can be problematic, particularly in some patients where the apex may be thin, friable, and unreliable for hemostasis, whereas the aorta is something that we, as surgeons, cannulate every day. We put large cannulas into the aorta for heart-lung machines, so transaortic access is something very easily adopted by surgeons. We started this technique in March 2013, and in the last year, we have done well over 50% of our TAVR cases, maybe even 70% of our cases, through this route. We recently reviewed our outcomes data and found our paravalvular leak rate in our transaortic cases was lower than with transfemoral, and our radiation exposure was significantly lower as well, because we don’t do balloon valvuloplasty. We put the valve inside of the sheath. We actually pass the sheath with the introducer into the left ventricle. We don’t have to balloon dilate. We just put the valve in the ventricle and draw it back, do one run, and implant. The contrast load is less, the operative time is frequently under an hour, and the reliability of the implant is quite good. Because you are working such a short distance from the aortic valve, the ability to move the valve throughout the implantation period, while inflating the balloon, allows implantation where you want it. During transaortic implantation, the movement of the catheter 1 mm moves the valve 1 mm. The lack of stored energy in the catheter, which is common in transfemoral, allows easier and more accurate implantation. Our cardiologists who are also performing the transaortic deployment confirm the improved reliability of this approach. We have not implanted a second valve due to paravalvular leak in our transaortic experience.

Would that account for the higher paravalvular leak you saw in your transfemoral cases?

I believe that the attack angle is as important as the valve to ensure good seal and freedom from leak. The angle of approach and the fine adjustments of deployment that the transaortic approach affords seems to lower the incidence of paravalvular leak. I think that is true. Paravalvular leak is something surgeons have never seen before with a valve implant. It is something we wouldn’t tolerate in the open setting, and really, if we are going to offer patients something better than open surgery, in terms of lowering the risk of implantation, then we want to strive for zero paravavular leak. 

What aspects of imaging technology have proven beneficial for you?

Transesophageal echocardiogram is helpful for paravalvular leak and during the implant series. Computed tomography (CT) scanning and the assessment of the valve area implant zone has been a major evolution. CT has helped us a great deal with valve sizing and made it more reliable. The CT is particularly important with the transaortic approach as we look for the angle of approach to the valve, the anatomy of the ascending aorta, and plaque within the aorta. It is very important to have time allocated for cardiologists with interest in imaging to evaluate these scans. In these frail patients, it is hard to find a part of the process that doesn’t require time and attention. If you try to compromise and do not have the appropriate person spend the necessary amount of time to assess for accurate valve size, you end up paying in the long run. Pushing to get these physicians involved, and making sure they have adequate time to do what they need to do, is really important. It has been key to our success. 

Can you talk about the importance of answering as many questions as possible in advance of the actual procedure?

I tell patients that we don’t go to the operating room and do exploratory heart surgery. It is the same thing with TAVR. Every question has to be nailed before you walk in the room, and everyone has to have signed off on it. Before we walk into the room, the checklist has been done. The valve size has been determined, we know the angle of deployment, we know the route that we are going to implant, and we know the special considerations, particularly for complex pump assist cases or concomitant coronary stenting or TAVR. All of the issues are laid out before we walk in there. We do not want to be sorting through things on the fly. If you do that with these patients, you are going to end up with trouble. 

How has the TAVR program affected your community and Mission Heart?

We have a very robust valve program and do over 400 valve interventions per year. We do a lot of complex valve work on the surgical side, such as double and triple valves, as well as valve repairs, aortic, and of course, mitral. TAVR is another complement to our ability to offer patients both in and outside our region, options that give them the highest possible level of care. We have results that are very good, and we try to improve every time we walk into the OR. We offer a care delivery strategy that is very patient and family centric, with an understanding of the significant challenges of working with patients in this demographic, and how difficult it can be for them to meet multiple appointments. We try to bundle as much as we can. We like to have the patient come into the valve clinic and by the time they leave, have a plan and the date with a full understanding of all the issues. That is our goal: to make it as easy as we can, and use frequent touch with the patient and their family via our coordinators, to make sure that questions are answered, and patients and their families have a full understanding of what we are doing.

Any final thoughts?

Visitors who come to see our program say that Mission Heart offers one of the most integrated programs they have seen, and I think that is why we are experiencing such success. Egos are left at the door. It is all patient-centric. We have a team that works together, to support our mission of delivering the best care in a fashion that results in an enhanced patient and family experience.   

III. Joshua Leitner, MD, Asheville Cardiology Associates, a Mission Health affiliate.

Can you describe the Mission Heart TAVR program from your perspective as an interventional cardiologist?

The TAVR program began before I came to Mission. I have been here about two years. It was built on the foundation of a history of great work by our cardiology and cardiac surgery groups. These groups have historically worked well together, basically building a center that was very experienced in the medical and surgical care of valve patients long before TAVR existed. More specifically, my colleagues Dr. Bill Abernethy (interventional cardiologist) and Dr. Mark Groh (cardiac surgeon) really took the time and laid the foundation to develop a TAVR program here at Mission. It is important to think about TAVR as a tool in the treatment for a disease state, and not a procedure in and of itself. The program has enjoyed success, and we also have buy-in from administration and support on many levels. If I had to describe a primary reason for our program’s success, it may sound a little clichéd, but it is still fundamentally true — TAVR requires intense partnership between people who haven’t traditionally worked in the same room together: cardiologists and cardiovascular surgeons, imaging, anesthesia, cath lab staff, surgery staff, and a lot of work before and after the procedure. 

Can you address support from administration?

Our administration took a very long view and they have been supportive from the beginning. Among other things, they have built a hybrid room and a wonderful clinic for us to work in, that the patients like a lot. As we have grown the program, the financials have come along, and we have made the program workable, but our administration has always stood by us and been very supportive. I don’t think we would have had the ability to grow the program without that sort of vision, and more than vision, the fortitude to stand through the challenges. 

What are some of the strengths that as an interventionalist, you bring to this multidisciplinary team?

A multidisciplinary program like TAVR is gratifying because while you bring something to the process yourself, you also end up learning so much from other members of the team. As an interventionalist, catheter-based technique, vascular access, manipulation of catheters and wires, and interpreting hemodynamics are what we do every day. 

The understanding of fluoroscopy and how to lay out the views, how to correlate it to echo or CT views, is an important cognitive skill that interventionalists bring to this procedure. But really, it is collaborative. When we are doing a procedure and I am the valve implanter, it feels like conducting a symphony, in many ways. There are lots of people involved, and part of your job is to help orchestrate even as you move the procedure along, but you rely on your partner’s eyes and input. It’s very different from doing something like a percutaneous coronary intervention (PCI) where you can manage every component yourself.

What are some of the clinical challenges you face with these patients?

Right now, TAVR is only available for inoperable or high surgical risk candidates, which means that all our patients carry comorbidities, and what’s challenging and enjoyable is that each case is completely unique. You don’t know what the challenges are going to be with each patient, but each patient comes with them. Part of the satisfaction is in problem-solving, whether it is a technical aspect regarding valve deployment, or a clinical aspect of managing renal dysfunction and being very meticulous with your contrast and imaging, or vascular disease and having to get creative in the hybrid room or cath lab in dealing with it.

As smaller valves become available, do you think conscious sedation might become more prevalent for patients receiving femoral access?

There is a healthy debate in the world of TAVR on this topic. Clearly, there is a big move toward conscious sedation in select patients. The early ambulation and early discharge data is impressive. Now that the U.S. has commercially available, smaller-caliber valves, we are going to see much more of a trend toward conscious sedation and there are obviously advantages to that. 

Transesophageal echo (TEE) is linked to this issue as well. Patients feel more comfortable with TEE under general anesthesia. I am in the camp that believes that intra-procedural TEE adds a lot of value. It is one of the issues that we are going to have to figure out how to manage as the use of conscious sedation grows. More and more operators are actually doing without TEE, which is interesting. We have done a handful of cases without TEE and learned from experience that you absolutely need to make sure that your imaging and surface echo windows are perfect ahead of time. Some people are using very good transthoracic capabilities, and some have used intracardiac echocardiography (ICE). I think you have to go into the procedure with every single one of your questions answered up front if you are going to do that, and have a clear plan for the critical early evaluation of the valve once it is implanted.

Conscious sedation is going to happen in select patients. It is something that achieves the promise of TAVR, the minimally invasive aspect. Every patient has some risk with general anesthesia, every one of these patients has some risk with intubation, and for selected patients, I think conscious sedation will really offer an advantage. But they’ll end up losing overall if the valve implant is compromised in any way. Anything less invasive or less sedating, including the use of medications with fewer complications, is better, so long as the patient comes out with a well-placed valve without leak. 

Is your program using both CoreValve (Medtronic) and Sapien (Edwards Lifesciences)?

We have only been using Sapien and we are exploring CoreValve. We are going to be enrolled in a self-expanding valve clinical trial, and we want to focus our experience on a handful of platforms so we can really offer a wealth of experience with each. 

In terms of the procedure itself, which is typically more challenging, access or positioning the valve?

I am going to quote one of my mentors, Dr. Mark Reisman. He said that the cognitive aspects of TAVR are far more challenging than the technical aspects of the procedure; and if you make the effort to really work on those, the rest will fall into place. The difficulty in positioning the valve, at least part of it, is related to how well your imaging has been done up front and how well you understand the anatomy: if the imaging lays out the valve deployment angle, and you are meticulous about having that right, it helps make a challenging procedure more straightforward. Likewise, if you don’t have imaging done properly before implantation, it can take an otherwise straightforward procedure and make it challenging. Vascular access, frankly, we have not struggled with, and that is partly due to the fact that we have taken a relatively conservative approach. We have predominantly used surgical access and closure for our femoral cases, and have a low threshold to move to a non-femoral approach if we had concerns about the vascular access — we’ve had a very good experience with the transaortic approach. As a result, we have had extremely low vascular complication rates. Now that the Sapien XT and smaller diameter sheaths are available, we have done percutaneous access, but will not push it with questionable vessels.

As you look ahead, what do you see happening with your program and with TAVR?

What I think is happening with us is similar to what I hear happening in the community as we attend conferences: better integration of imaging, and lesser invasive procedures. I can’t emphasize how critical pre procedural imaging is, and it is still evolving; we have yet to fully master this. We are becoming more savvy about fine-tuning CT and 3-D TEE, and we have a great imaging team; we are understanding how to adapt valve selection, sizing, and positioning to imaging, both pre procedural and intra procedural. So tightening the screws on imaging — that is a lot of the work right there. Obviously there is a lot of excitement about next-generation valves, and the technology will help deal with paravalvular leak, and hopefully smaller size catheters will mean shorter hospital stays. The future is going to be less and less invasive, trying to minimize lines, minimize intubation time, and even more, achieve that promise of TAVR by doing things less invasively, more of an alternative to open surgery, even in the non-femoral cases. At the same time, we all need to be smart about identifying the cases where the anatomy just isn’t right for the limits of TAVR.  

You mentioned that is best to see TAVR not just as a procedure. Can you expand on that?

It is a tool for a disease state. The best programs will have a comprehensive approach to the disease state of valve disease, to grow the program from a foundation of good diagnostic imaging and medical management, judgment about timing of intervention, and knowing that many valve patients will benefit from traditional surgery, as well as seeing that some anatomies will pose real challenges for transcatheter heart valves. Working closely with the surgery program, not trying to compete for patients, is fundamental. For the patients triaged to TAVR, partnering with the patient’s existing providers is key, because we need to understand their medical issues in depth, aside from their aortic stenosis. We spend a lot of time dealing with non-cardiac issues, especially post procedure. That is a big part of the care and it is important to have top-notch coordinators who can manage it. Our coordinator, Dana Triplett, is a wonderful example of that.

I want to make sure that I say enough about teamwork. It is no coincidence that the initial trial was called the “PARTNER” trial. TAVR requires teamwork on a level that I have never seen before in cardiology, from the administration, from the physicians, from the different multidisciplinary aspects, to the people in the room. We have seen OR staff and cath lab staff come together and learn from each other, and evolve into their own unique team. We have seen teamwork among the care providers, our TAVR clinic coordinators and our TAVR clinic nurses. It is just amazing to see this many people come together and work on a program. The program can be successful because of that group effort.

Do you think that everyone at the beginning had an awareness of the level of teamwork required?

I think there was, frankly, a modest amount of skepticism. Everybody was comfortable in their own skills, and everybody felt a little out of place because there were skills needed that were outside of anyone’s individual skill set. What’s amazing is the level of comfort and the familiarity — basically, how automated some of these procedures have become. We’ve learned to trust each other. TAVRs are no longer ‘events’, but are becoming more standard cases. There are moments in nearly every case where somebody’s skill set is called into action, and it is often a different person each time. It is that cohesion of the team that saves the day.