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. 2022 Jan 21:9:74-81.
doi: 10.1016/j.xjon.2022.01.015. eCollection 2022 Mar.

Physicians' perspectives and attitudes toward surgical bailout in transcatheter aortic valve replacement

Alexandria J Robbins  1   2 , Stuart W Grande  3 , Fatima Alwan  1 , Matthew R Soule  4 , Ganesh Raveendran  5 , Gregory Helmer  5 , Rafael Andrade  6 , Tjorvi Perry  7
Affiliations

Physicians' perspectives and attitudes toward surgical bailout in transcatheter aortic valve replacement

Alexandria J Robbins et al. JTCVS Open. .

Erratum in

  • Erratum: Notice of Correction.
    [No authors listed] [No authors listed] JTCVS Open. 2022 Jun 7;11:414. doi: 10.1016/j.xjon.2022.06.004. eCollection 2022 Sep. JTCVS Open. 2022. PMID: 36172413 Free PMC article.

Abstract

Objectives: The incidence of surgical bailout during transcatheter aortic valve replacement (TAVR) is ∼1%, with an associated 50% in-hospital mortality. We performed an exploratory qualitative study of TAVR team perceptions regarding routine surgical bailout planning with patients.

Methods: We developed a semistructed interview guide to explore clinician perspectives on the TAVR consent process, managing intraoperative emergencies, and involving patients in surgical contingency planning. We interviewed surgeons, cardiologists, and anesthesiologists involved with TAVR in 4 hospitals. We performed qualitative thematic analysis via independent coding of salient quotations from the transcribed texts. Codes were categorized based on shared meaning and the final themes were derived by identifying key content, and examining its relational nature.

Results: Thirteen interviews were conducted, identifying 4 major themes. Participants agreed that eliciting patient preference for bailout is crucial, particularly when surgical outcome is ambiguous. In those cases, participants offered criteria for determining which patients should be engaged in a more nuanced discussion. The ethos of specialty clinicians impacted anticipation and response to procedural emergencies. Finally, physician attitudes reflected strong emotional responses to patient death/morbidity, particularly in iatrogenic injury. Participants expressed anxiety with performing TAVR without surgical backup, while also demonstrating willingness to respect patients' wishes.

Conclusions: The TAVR team supports engaging patients regarding potential surgical bailout and honoring their preferences in the event of complication. However, clinical judgment about the expected outcome of bailout would frame that discussion. Participants described the emotional weight of not pursuing bailout if indicated and the importance of good coping mechanisms.

Keywords: STS, Society of Thoracic Surgeons; TAVR, transcatheter aortic valve replacement; intraoperative emergencies; shared decision-making; surgical palliative care; transcatheter aortic valve replacement.

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Figures

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Graphical abstract
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Involving patients in surgical bailout planning.
Figure 1
Figure 1
The interviewed TAVR physician team expressed a commitment to emphasize patient autonomy while guiding the decision-making based on clinical experience. Despite the multidisciplinary nature of the TAVR team, many participants reported collaborative ownership of intraoperative decisions. Finally, participants discussed the emotional toll of poor outcomes on the TAVR team, particularly if the decision did not seem to be patient goal-concordant in retrospect. Implication Statement: Consent for TAVR should include a more nuanced conversation regarding planning for potential complications. TAVR physician team members should develop a standardized way to approach this. TAVR, Transcatheter aortic valve replacement.
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References

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