Dr. Eric Munoz: Offering life-saving TAVR in… - Wyoming Medical Center

Dr. Eric Munoz: Offering life-saving TAVR in Wyoming was a two-year journey

By Eric Munoz MD Mar 6, 2020

On Thursday, March 5, cardiac surgeon Eric Munoz, MD, and interventional cardiologist Adrian Fluture, MD, FACC, FSCAI performed the state's first two transcutaneous aortic valve replacements (TAVR) at Wyoming Medical Center. Dr. Munoz described the two-year process to make this possible in a Facebook post, which we are publishing here with his permission.

Post author Eric Munoz, M.D., a cardiac surgeon, at right, poses with physician assistant Andrew Brown just before Wyoming's first TAVR procedure on Thursday, March 5, at Wyoming Medical Center.

Yesterday was one of the greatest days of my professional career. My colleague, Dr. Adrian Fluture, and I performed the first two transcutaneous aortic valve replacements (commonly referred to as TAVR) in Casper, Wyoming, at Wyoming Medical Center (WMC).

For those of you not familiar with the procedure, we replace the aortic valve through the groin without having to open the chest to perform open-heart surgery. Before yesterday, Wyoming was the only state in the nation that did not have a TAVR center. Our patients would have to drive hundreds of miles to undergo this revolutionary procedure. We are now proud to say that we can do this procedure at Wyoming Medical Center.

We embarked on this journey to bring this revolutionary medical technology to our medical center almost two years ago. Dr. Fluture and I were evaluating a patient in the ICU on a Sunday afternoon when I said, "Adrian we need to start a TAVR center, because if we don't our cardiovascular program will be left behind the rest of the nation and we will cease to exist as a major cardiovascular center."

It was becoming apparent to me that replacing the aortic valve through a TAVR procedure would soon become the predominant way of performing aortic valve implantation.

At that juncture, Medicare requirements to start a TAVR center required that the host institution perform 50 aortic valve procedures a year. At that time, we were only doing 25 to 30 per year and didn't meet the requirements. Dr. Fluture and I didn't know how we would do it but we started actively looking for cases and our volume increased.

We met with the TAVR team from Edwards Lifesciences and formulated a strategy to bring TAVR to WMC. Initially the TAVR procedure was only approved for high-risk cases but was about to be approved for intermediate risk patients, and we heard that trials for low-risk patients would begin soon. We knew that once the procedure was approved for low-risk patients, everyone needing aortic valve replacement would have to travel out of the state if we didn't do TAVR at WMC, so the race was on. We met with administration and they got on board with our quest.

Then, Centers for Medicare & Medicaid Services (CMS) announced that they were going to meet to discuss changes in the requirements to start a TAVR center. A consensus document was written by a panel of experts at high-volume TAVR centers proposing to increase the requirements to do TAVR at any given hospital, and we knew that if that document became law our quest would be dead. Dr. Fluture and I, with the help of the Edwards team, began lobbying CMS to reconsider the proposed requirements for establishing a TAVR center. We also lobbied with Wyoming's senators, Mike Enzi and John Barasso, to get behind our cause and help lobby CMS. Of course other physicians in other rurals areas of the country expressed many of the same concerns we had, but I believe we were the most vocal.

Our efforts did not fall on deaf ears, and the new proposed regulations were favorable for us to begin a TAVR program. CMS opened another comment period. We heard rumor that experts at high-volume centers were going to propose changes to the law that were not favorable to our cause. We wrote more letters to CMS.

Post author Eric Munoz, M.D., a cardiac surgeon, at right, poses with physician assistant Andrew Brown just before Wyoming's first TAVR procedure on Thursday, March 5, at Wyoming Medical Center.
Post author Eric Munoz, M.D., a cardiac surgeon, at right, poses with physician assistant Andrew Brown just before Wyoming's first TAVR procedure on Thursday, March 5, at Wyoming Medical Center.

The requirements were reduced and the new finalized regulations were favorable to us. You don't know how we felt when we read the new requirements. It meant that we now could conceive of the day when we would be doing TAVR at WMC. Of course it also meant that all eyes in the TAVR world were watching us. It's amazing that everyone in the TAVR universe was following our story. This was in July of 2018.

At this time, Michele Chulick, President and CEO of Wyoming Medical Center, came fully on board with helping us bring TAVR to WMC. Dr. Fluture and I then began training. We went to TAVR courses and visited other hospitals in our region to begin training to do the procedure. We then went to a mini internship in Munich, Germany, for two weeks to learn how to do the procedure.

The knowledge we gained from doctors Jonno Michel and Markus Kasel at the Heart Center in Munich was invaluable, and we can't thank them enough. Next we went to Albany Medical Center where we received more hands-on training from Gus Delgado to enhance our skill set. Thank you Gus for your support.

In the meantime, we had to figure out where we would do the procedure at our hospital. Initially we thought we would do it in our existing cath labs, but we soon realized we were limited by space and that we did not have the room for the bypass equipment to do rescue surgery if we had a major complication. The hospital was building a brand new Hybrid OR Suite for the radiologists. It was decided that we would do TAVR in this brand-new Interventional Radiology Suite. This room is state-of-the-art and is one of the nicest Hybrid OR rooms I have ever seen.

Next, the planning sessions began. It is mind boggling how many moving pieces there are to bring a procedure and program like this to fruition. There are hundreds of details that have to be addressed to make this happen. I can't thank the team enough for the countless hours they devoted to making this happen: Mica Elmore, R.N., cardio service line coordinator; Haylee Todd, R.N.,valve clinic coordinator; John Poole, my CV nurse coordinator; Karen Buck, OR director, and my entire heart team, the cath lab team, my perfusionists, and our cardiac anesthesiologists. And, of course, we thank the Edwards team for all the support they have given us along the way: Roger Riggs, Gary Chase and Carmen Dalqhuist Their partnership with us is first class.

All of the hard work and preparation finally paid off.

Yesterday, Dr. Fluture and I performed the first TAVRs in the state of Wyoming. The procedure was performed with Dr. Todd Witzeling, our anesthesiologist, and Dr. Quang Bui from UCLA Harbor Medical Center, our physician proctor. We finally achieved our goal after two years of hard work and planning. Thank you to the administration, and our course my friend and colleague, Dr. Fluture, for making this a reality. This will truly benefit the great people of Wyoming and we are proud to bring this technology to Wyoming to help them.

Professional headshot of

Eric Munoz M.D.

Dr. Munoz is a cardiac surgeon at Wyoming Cardiac and Thoracic Surgery in Casper. He is board certified in thoracic surgery and general surgery.