#TAVR Case Reports on Twitter Paint Rosy Picture

Operators are keen to put their best foot forward when posting their TAVI cases on Twitter, where results appear far rosier than would be expected in the real world, according to a new paper published in EuroIntervention.

This disconnect raises concerns about how Twitter is being leveraged for learning opportunities, the researchers say, since there appears to be “strong selection bias in both the types of cases being reported and also their outcomes.”

“Leading up to the paper we recognized that all of us use Twitter to share information. We all use it as an educational tool, a social tool, etc,” said lead investigator Sarah K. Gualano, MD (University of Michigan, Ann Arbor). “But increasingly our perception was that cases were being presented with little follow-up and almost no signs of any negative outcomes. You suspect that’s happening, but the real question is: what’s the prevalence of complications?” Another point of interest, she added, was how those reports matched up with “well-established data that we have from clinical trials and registries of what we know are the expected outcomes for TAVR patients.”

Gualano told TCTMD she was inspired to undertake the project when she spotted an unsettling social media post: “What really sealed the deal on the need to do this study is [when] I came across a tweet where an operator said they had seen a particular technique on Twitter one day and then used it in a TAVR the next day. It’s not to say that was wrong, but I just think that we need to be cautious about how we’re disseminating information over Twitter.”

The researchers acknowledge that most #CardioTwitter users know there can be downsides to social media, among them FOMO—the fear of missing out. “Awareness of pitfalls of social media is increasing in the general public. Physicians, too, must be vigilant to prevent our practice from being unduly influenced by our social media experience and suffering interventional FOMO,” they stress.

“Despite growth in users of social media platforms across areas of medicine like interventional cardiology, there has been little written on, or formal scrutiny of, educational content in these settings,” they observe, later adding, “The stakes are high in these open forum conversations regarding potentially life-altering interventions. We must commit to using Twitter wisely.”

High Success, Few Problems

Gualano and colleagues searched Twitter for #TAVR-tagged videos of cases between June 2019 and May 2020, excluding retweets, ads, published reports, and unrelated or incomplete cases. In all, 499 tweets met those criteria, with 83 users describing 170 unique cases.

All of the cases were successful. Just six (3.5%) used nonfemoral access. None involved death or stroke, and there were no reports of permanent pacemaker implant or paravalvular leak worse than mild. The tweets mentioned one MI and three vascular complications, for a rate of 1.8%.

Moreover, the researchers say, “there was substantial missing data” related to death, stroke, MI, or procedural complications. “Assuming missing data would be interpreted by the reader as not occurring, overall rates of outcomes were much lower than reported in clinical trials or registries,” they write.

Also “worrisome” is that just two cases (1.2%) were said to be posted with permission, the investigators report, noting, “Patient privacy has also been often overlooked with cases posted on Twitter. Even if deidentified in the traditional sense, other content such as procedural date or its unique features may result in patient awareness of posting of their procedure.” This is especially true since many physicians list their names and institutions on their Twitter profile, Gualano, pointed out. “Many of us have patients who follow us on Twitter, so I think that risk is very real.”

The researchers conclude that their study shows the “importance of registry data and institutional quality reviews to counterbalance the Pollyannaish view we may develop from social media. Avoiding over-optimism in Twitter users may be especially true for new or high-risk treatments like TAVR where innovation occurs regularly and evolving practices may proliferate.”

Message Isn’t ‘Don’t Use Twitter’

Mohamed Abdel-Wahab, MD (Leipzig Heart Center, Germany), commenting on the results, told TCTMD he doesn’t post details on his own cases but rather uses the site to communicate with colleagues and learn about the latest research papers. Tweeting out a case is far different from going through the peer-review process to publish a case report, emphasized Abdel-Wahab, who said he wasn’t surprised to see such optimistic posts online.

“I think this is more or less normal when people post things about themselves: it’s not edited, it’s not reviewed, it’s not censored. This is probably a natural thing, to post the good things,” he observed. “It’s quite unusual to post complications or bad things, unless you manage the complication in a heroic way—then you’ll be interested in showing your skills.”

Another challenge relates to privacy, said Abdel-Wahab, in that cultural and legal standards vary across the world with regard to what information can be revealed about patients. “With Twitter and social media, there are no boundaries. Countries have different rules and regulations, so what seems to be unethical in the United States could be very normal in other countries,” he said, noting that there are no set standards for what should and shouldn’t be posted.

Abdel-Wahab said he does see room for learning new techniques. But he cautioned that, unlike with lighthearted personal posts, Twitter shouldn’t be used as a “promotional platform” for a matter as serious as medicine.

Gualano believes cardiologists who share their experiences have good intentions. “It’s not to say, ‘Don’t use Twitter.” It’s just [important to] read everything with a little bit of caution and recognize that we’re all going to put our best cases forward and have less likelihood to share some of the negative things that can happen to us as operators,” she advised.

What might help is specifying what happened after the TAVI is done, she suggested, “because for all we know, these extremely high-risk situations or complications that have been salvaged in the procedure wind up with a negative clinical outcome in the long run.” It also would be interesting to see how Twitter behavior evolves as operators become more judicious in tweeting, said Gualano.