What’s in a Name: Is It Time to Choose Between TAVI and TAVR?

The procedure that delivers a bioprosthetic device through flexible tube to a patient’s failing aortic valve didn’t originally have a name when it debuted more than 20 yours ago. Now—to the chagrin of some but not all—it has two.

Transcatheter aortic valve implantation (TAVI) and transcatheter aortic valve replacement (TAVR) refer to the exact same intervention, one that has experienced massive growth and saved many lives over its history. Yet TAVI is more often used in Europe and Asia, while TAVR is more common in the United States.

Some cardiologists argue it might be time to change that and instead agree on a universal term to eliminate any chance of confusion. Others contend that this semantic fight isn’t worth the effort when issues like valve durability and patient education remain to be improved.

“There are many people that are working in the health system that are not experts in interventional cardiology,” said Ciro Indolfi, MD (University of Calabria, Cosenza, Italy), who was the lead author of an editorial published earlier this month in the European Heart Journal arguing in favor of a single acronym. Using multiple names for the same procedure “can generate mistakes and can also [be] negative for patients,” he told TCTMD.

The paper highlights the potential for confusion and calls for international cardiology societies to coalesce behind a single acronym.

Specifically, Indolfi believes TAVI is the proper choice as it more appropriately describes what is done—to the extent he authored not just one but two papers on the topic. “While surgery removes the native valve for implanting a new biological prosthesis (ie, the term replacement is correct), transcatheter treatment involves crushing the aortic valve leaflets (not removal), which remain in situ after a new percutaneous biological valve implantation,” he writes in the second editorial, this one published in the Journal of Cardiovascular Medicine

“It’s not reasonable” to have two names, Indolfi said. One of his trainees confused by the existence of both terms once asked him if TAVI and TAVR were offered to patients with different diseases. He acknowledged the acronyms’ long histories but argued that “this doesn’t mean that we should [continue to] use two for the next 20 [years].”

A History Lesson

Indolfi is technically correct, at least from the perspective of any dictionary. Replacement means to put something new in place of, but this is not done during the transcatheter procedure, which instead renders the native valve inoperable by using it to anchor a new bioprosthetic valve.

That said, the intervention does result in a “functional replacement” of the valve, according to Martin Leon, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), who led the first trials in this field. “Even when you do [surgical] aortic valve replacement, you’re not replacing the aortic valve complex, which includes the sinuses [and] the proximal aorta,” he said. “So, to me, the concept of replacement was more accurate and consistent with what we’ve been doing surgically for a long time.”

The initial case report from 2002 used a mouthful for the procedure: percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis. When it became obvious that it needed a more concise name, Leon had many discussions with the late Alain Cribier, MD, about what was best.

“He wanted to use the term percutaneous because he liked the term percutaneous heart valve, and I made the case that we had founded TCT and we called it transcatheter, and the term transcatheter was really derived historically back to the mid-1980s,” Leon recalled. Transcatheter was “more descriptive” and generic, he said, and could be applied to all devices that could enter the body through the vascular tree and not necessarily only those that come through the skin.

Cribier was drawn to TAVI, as the same sounds in French—ta vie—translate to “your life,” according to Leon. “He was very romantic and he was very personal about this, and he felt that this was a therapy that saves your life,” he said, adding that he himself was “swayed” even though the word implantation “doesn’t roll off the tongue and it doesn’t mean very much to lay people.”

To me, the concept of replacement was more accurate and consistent with what we’ve been doing surgically for a long time. Martin Leon

The first PARTNER trial manuscript in 2010 used TAVI, but the researchers quickly faced pushback from US regulatory authorities questioning how they would codify reimbursement for a procedure that essentially had the same result as surgical AVR but had a fundamentally different name, Leon said.

“The fact that it wasn’t called a replacement meant it was difficult for them to use the same coding specifics that are used for surgery,” he explained. Fearful of issues with reimbursement, the researchers changed the name to TAVR in their second paper, which was published less than a year later. “We thought a lot more about it, to be honest, and felt that replacement was a more accurate and reasonable term to actually describe what we’re doing.”

Eliano Navarese, MD (University of Sassari, Italy), agreed that clinical function “may matter more than semantics” in this regard. “Even if the old valve remains, functionally the prosthetic valve replaces its role, [thereby] making replacement a reasonable term,” he told TCTMD, adding that this is important considering the unanswered questions about valve durability and the work that still needs to be done in this area.

Guideline Changes

In 2020, the writing committee for the American College of Cardiology (ACC) and American Heart Association (AHA) valvular heart disease (VHD) guidelines threw their support behind TAVI to align with the Europeans. TCTMD soon changed its style to reflect this development, but it seems few American physicians followed suit.

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center), didn’t recall the change in the guidelines and said he never hears his American colleagues use TAVI. “Even the Europeans who trained in Europe and come here call it TAVR,” he told TCTMD. “Or if it makes them uncomfortable, they basically say valve replacement.”

Leon called the 2020 VHD guidelines change a “frivolous decision that was made by a few people in the moment in response to a minor fear that was raised by the Europeans.”

Both acronyms accurately reflect the nature of the procedure, and for healthcare professionals, the difference between them is minimal and easily understood. Masanori Yamamoto

“Any conversations around that decision are confidential,” an ACC spokesperson told TCTMD, confirming that neither the organization nor its publication the Journal of the American College of Cardiology have an official policy for which name to use.

Guideline writers have a history of wanting to influence terminology, said David Cohen, MD (St. Francis Hospital & Heart Center, Roslyn, NY, and Cardiovascular Research Foundation, New York, NY), citing the 2019 European Society of Cardiology (ESC) guidelines changing the name of stable coronary artery disease to chronic coronary syndromes.

“The term is more accurate, but I don’t know that anybody [in the US] uses it,” he told TCTMD. “Sometimes it feels like a hammer looking for a nail.”

‘Football and Soccer’

The notion of a single consistent name appealed to most everyone who spoke with TCTMD for this story, but most acknowledged that’s unlikely to happen. Even Indolfi is “skeptical,” he said.

Likening the vernacular conundrum to the sports world, Tsuyoshi Kaneko, MD (Washington University School of Medicine in St. Louis, MO), told TCTMD that it’s the “same as football and soccer.” Everyone knows both words refer to the same game, but the regional nomenclature will persist due to a long history.

“That terminology, TAVR, has embedded into our daily practice so deeply,” he said. “It’s going to be so hard to remove. Even if the professional societies decide that we’re going to be calling it TAVI, I don’t think any of these communities will change the name to a ‘TAVI clinic.’ . . . The phonic tone has really been there for such a long period of time. It’s going to be so hard to change.”

If he had to pick a single name, Kaneko said TAVI would be more correct, “but I will guarantee you that I will keep saying TAVR in my daily clinic.”

That terminology, TAVR, has embedded into our daily practice so deeply. It’s going to be so hard to remove. Tsuyoshi Kaneko

Similarly, Cohen prefers to use TAVR but will edit presentation slides to say TAVI when giving a talk in Europe or Asia. “It wouldn’t bother me too much if we all harmonized, but I just don’t know whether that’s something that we should be worrying about and trying to codify.”

Cohen said he has encountered no issues of confusion with either patients or clinical colleagues.

Masanori Yamamoto, MD (Toyohashi Heart Center, Japan), also said he tends to change which acronym he uses when speaking with peers from Europe or the US, but he prefers TAVI with his patients. “Both acronyms accurately reflect the nature of the procedure, and for healthcare professionals, the difference between them is minimal and easily understood,” he told TCTMD in an email.

“Restricting or prohibiting the use of either term is not a realistic approach, and it is clear that this issue cannot be resolved simply through a vote for or against one acronym,” Yamamoto continued. “However, as with all catheter-based interventions, it is preferable for procedural terminology to be as standardized as possible.”

Finding TAVI easier to pronounce, Jack Wei Chieh Tan, MBBS (National Heart Centre Singapore), told TCTMD in an email he is “ok with both as [they] mean the same thing, [and there is] no confusion amongst the community when used interchangeably.” It’s unlikely that anything will change “unless either the Americans or the Europeans are keen to jump ship,” he added.

Leon agreed. “It’s going to be tough at this delayed stage now, more than 20 years after the first procedures, to recreate history and come up with a uniform single term,” he said, adding that with the development of new procedures to treat mitral valve disease, “nobody calls it TMVI—they call it transcatheter mitral valve replacement. And it’s essentially doing the same thing in that regard.”

Francesco Pelliccia, MD (Sapienza University of Rome, Italy), though, told TCTMD he’s “confident” that a single acronym—specifically TAVI—will soon be adopted by cardiologists. “In recent years, several [new] acronyms . . . have been proposed and rapidly adopted by the cardiology community,” he said in an email. “I do not see any problem at all.”

I’ve never been a fan, personally, of renaming things when there’s a history that one can be proud of. Ajay Kirtane

Megan Coylewright, MD (Essentia Health, Duluth, MN), commented to TCTMD that patients have many concerns over the current state of aortic valve therapies, but the name doesn’t seem to be one of them.

At a recent forum for patients with aortic stenosis, she reported, what the procedure was called was not brought up. But Coylewright pointed out that this presents “a great opportunity to say: ‘How are we doing with regards to patient engagement and education at this time?’ And there’s a lot of room for improvement and focusing on that is probably the most important message.”

While Coylewright does not see a current reason to pick a single term, she highlighted the importance of proper naming throughout the entire field. “It reminds me a little bit of the left atrial appendage occlusion space where we refer to those devices as Watchman devices, even when they’re not Watchman,” she said. “That’s not very helpful. It’s pretty confusing.”

Kirtane acknowledged that the conversion from TAVI to TAVR in the US to appease regulators and industry was potentially “opportunistic,” but the chapter has now been written. “I’ve never been a fan, personally, of renaming things when there’s a history that one can be proud of,” he said. “It might just be one of those things that, that each culture is different and, and we respect each of those.”