Aortic Stenosis, TAVRs, and Code Status: A Podcast with Gwen Bernacki and Ashok Krishnaswami

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of valvular heart disease for patients with severe aortic stenosis, a condition that affects one in ten adults older than the age of 80.  The rates of TAVR have also risen dramatically in the last decade. In 2019, the number of TAVRs exceeded surgical aortic valve replacement (SAVR) in the US for the first time.   

On today’s podcast we talk with two amazing cardiologists and researchers - Gwen Bernacki and Ashok Krishnaswami - about TAVRs in the elderly, including what it is, who gets it, and what the outcomes and complications look like after the procedure.   

We also discuss Gwen and Ashok’s mixed-method study in the Journal of the American Geriatrics Society (JAGS) where they interviewed TAVR coordinators across California and Washington State about how code status is managed within their programs, and compared programs according to their policies to assess differences in outcomes.  What they found was fascinating:

• Most programs require that DNR status be temporarily rescinded for the procedure. 
• The time required before DNR was reinstated varied substantially among programs (38% 30 days post-discharge).

Gwen and Ashok want to make it clear how thoughtful interventionists are about this topic for their patients — as this is very very challenging on a daily basis for them.  They also advocate for having more great minds at the table to help move the field forward (including geriatric and palliative care specialists!)

Here are more resources if you want to take a deeper dive into the subject:

• Geriatric and Palliative Care Specialists as Valued Members of the Multidisciplinary Heart Team. The American Journal of Medicine 2022
• The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS ONE 2017
• Beyond the Do-not resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients. Anesthesiology 2021