Aortic and mitral structural interventions in the absence of cardiac surgery

Traditionally, structural heart interventions have been performed at heart valve centres with on-site heart surgery to maximize expertise and deal with complications requiring emergent cardiac surgery (ECS). However, at present, only transcatheter aortic-valve implantation (TAVI) must be performed at centres with on-site heart surgery according to current guidelines, while mitral transcatheter edge-to-edge repair, or left appendage atrial occlusion could be performed also in centres without on-site cardiac surgery. Today, ageing of the population and improved results of TAVI have increased the need for such procedures posing strong pressure to traditional heart valve centres, prolonging waiting times for TAVI and increasing access disparities. Fortunately, TAVI procedures have a very low rate of complications, including those necessitating ECS, and observational data suggest that TAVI can be safely performed in centres without on-site cardiac surgery. However, guideline recommendations need randomized clinical trials like the TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial to be updated. The TRACS trial randomizes high-risk symptomatic aortic stenosis patients to treatment by the same operators either at centres with or without on-site cardiac surgery and compares 1-year follow-up. Key issues for structural interventions, in particular TAVI, at centres without on-site surgery are shared indications through heart team evaluation, consistent experiences and competences of non-surgical centres, and strong networking with the Hub centre. The increasing demand for structural heart interventions highlights the need for innovative care models and the careful introduction of a 'Hub-and-Spoke' approach for high-volume heart valve networks could be a study option.