July 16th, 2012
The Name Game: Why Did “TAVI” Suddenly Become “TAVR”?
Larry Husten, PHD
One of the great, unexplained mysteries of the cardiology world in recent years is the sudden name change from TAVI (transcatheter aortic valve implantation), which had been the universally-used name for the procedure during most of its development period, to TAVR (transcatheter aortic valve replacement) about the time when the procedure edged closer to U.S. approval.
Now, in a clever letter published in the Journal of the American College of Cardiology, Stacey Clegg and Mori Krantz “humbly suggest reversion to the archaic name transcatheter aortic valve implantation (TAVI).” When the procedure is explained to potential patients, they write:
We gracefully explain that we blow up a balloon, smash the old valve to the side, then implant a new one within their existing annulus. Their reaction is often one of bewilderment. This confusion is well founded. Webster’s dictionary defines replace as “to put something new in place of something else,” and implies filling a place once occupied by something removed. One does not have a muffler replaced at the local auto shop and expect to find the old one still in place. Technically, we are performing valve displacement. However, a valve displacement doesn’t sound like an advanced restorative therapy that marketing experts would embrace.
Clegg and Krantz write that TAVI was still in use in 2010 when the first PARTNER trial was published in the New England Journal of Medicine (“Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery”) but the acronym had been somehow magically transformed by 2011 when the second PARTNER trial was published in NEJM (“Transcatheter Versus Surgical Aortic-Valve Replacement in High-Risk Patients”).
Clegg and Krantz argue that “TAVI” should be restored as “the acronym of choice”:
Why does this matter? We contend that this is not merely semantic, because an accurate name for high-risk expensive procedures is pertinent to healthcare stake holders. It facilitates uniform communication among researchers, payers, regulators, clinicians, and, most importantly, patients. In a clinical landscape cluttered with jargon, we should strive toward verbal precision. Politicians, poets, and pollsters know that words matter. Powerful words launch social movements and even cultural revolutions. The right catch phrase also can launch a new product. However, there should be truth in advertising, and our regulatory bodies should be critical in determining if advertising is misleading or fails to disclose all the relevant facts.
There is one issue about the name change not addressed by Clegg and Krantz, and here we leave the idealistic world of semantics and philosophy and enter the hard-edged world of economics and finance. At the time of the change from TAVI to TAVR, there were numerous rumors and speculations about the real reason for the change. Reimbursement for the procedure, the theory goes, would be much higher if it were based on a comparison with surgical replacement rather than surgical repair.
Bingo. Your last sentence is correct.
Also, “transcatheter” is a bad term. Precutaneous is better because many cases are place by trocar and not catheter.
Agree, last sentence may be the key for the change—I find this whole issue fascinating and emblematic of the many “non medical” issues that keep creeping into the practice of medicine. For the record, I feel that TAVI just sounds better.
Deeb N Salem MD
Chairman of Medicine
Tufts Medical Center
I don’t think this is a silly discussion — although many of my colleagues do. But I have to disagree that TAVI is more “accurate” than “TAVR” and/or more descriptive of the procedure — which actually destroys and “replaces” the malfunctioning aortic valve by a “transcatheter” approach. I applaud “precision” and appreciate “descriptive elegance” in nomenclature, but I think that TAVR is more precise and elegant (the new valve may be “implanted” but is clearly a “replacement” for the dysfunctional valve , rendering it completely nonparticipatory in cardiac function) — and the replacement function is really the critical one. Let’s face it — the old valve is a disaster – with dire cardiac and hematologic consequences (e.g. low cardiac output, syncope and acquired von Willebrand’s disease) – and the new one, interloper that it is, replaces the dysfunctional valve, takes up the burden of rationing systemic blood flow- and gets to where it assumes its new job, deployed by a catheter.
Terminology is tricky. There are many examples of medical terminology that purport to describe a clinical condition or procedure and require long discussions with trainees and patients as to how the procedure and its name came about, because a complete understanding of how the procedure works and what benefit it results in, is not inherent in the procedure name — often because a complete understanding of the procedure’s outcome and mode of efficacy was not evident when it was first performed. Medical personnel accept this; patients accept it, if it is explained, and often feel that they have been invited into a medically intimate space– where they have knowledge that is not accessible to the general public. Most physicians are practical people, neither grammarians nor linguists — a select few address the semantic and linguistic questions made important by discussions such as this one. The financial issues raised in the above discussion are not trivial. I think that the most important considerations are not related to nomenclature or finances, rather the considered value of an hypothesis or the data that support an experimental or established therapeutic procedure. Folks who undergo a transcatheter aortic valve implantation (TAVI) or replacement (TAVR) — whatever it is called, it is the same procedure– if they are well-chosen, avoid a major surgical procedure and regain both improved hemostasis and a return to everyday function. Expensive, yes — but not compared to surgical aortic valve replacement — and not unreasonable. The costs of such interventions, compared to those incurred by other life- but not function-sustaining strategies employed by other medical disciplines- e.g. chemotherapy for hopelessly unresponsive malignancies–should be assessed. Cardiac disease trumps cancer in terms of mortality, morbidity, hospital admissions many times over. Aortic stenosis is a disease of an aging population with a high incidence of bicuspid valves. Transcatheter interventions promise functional improvement for many with minimal morbidity and decreased cost.