Community heart programs and cardiac surgeon staffing: what the TAVR rules require

Photo: National Cancer Institute / Unsplash

Transcatheter aortic valve replacement is performed in the cath lab, but a TAVR program still depends on its cardiac surgery service. A hospital that offers TAVR to Medicare patients has to keep a cardiac surgeon on its heart team and a cardiac surgery program on site. Since September 2026 the minimum is a single surgeon with privileges, which means one departure can put the whole structural heart service at risk.

Replacing a cardiac surgeon takes a search, then credentialing and hospital privileges, before the new surgeon can operate. Programs that start only when a resignation letter arrives, whether they recruit in-house or through a firm like MASC Medical, can find that the gap outlasts the notice period.

What the new coverage decision kept and dropped

Medicare sets the institutional conditions in its national coverage determination for TAVR, revised in September 2026 after a nine-month review. The previous version, in force since 2019, asked a hospital opening a program for at least 50 open heart operations in the prior year and at least two physicians holding cardiac surgery privileges. The revision removes the hospital volume requirements. What remains is a heart team with at least one cardiac surgeon and one interventional cardiologist, each holding privileges at the hospital, alongside on-site structural heart and cardiac surgery programs and an intensive care unit staffed for patients recovering from open heart valve surgery.

Patient evaluation changed as well. The old rule required a cardiac surgeon and an interventional cardiologist to each examine the candidate face to face. Under the revision, the heart team’s initial review can be done asynchronously from the medical record, and the only mandatory in-person visit is with a physician who performs the procedure, who can be a cardiologist or a surgeon. A single operator may now perform the TAVR. The Society of Thoracic Surgeons has said the decision does not incorporate all of its recommendations on cardiac surgeon involvement, so the surgeon’s place on the team is likely to remain a point of debate.

The generalist cardiothoracic surgeon is getting older

Smaller hospitals have long relied on surgeons who operate on both the heart and the lungs. That group is now the oldest in the specialty. A 2025 study of board-certified thoracic surgeons in JTCVS Open used the module each surgeon chose for the maintenance of certification exam as a proxy for what they actually do in practice. About a quarter chose the broad cardiothoracic module, and their mean age was 63.3 years, three to five years above the surgeons who chose the adult cardiac or general thoracic modules.

Younger surgeons are taking the narrower routes, toward adult cardiac, general thoracic or congenital surgery, and the authors describe the specialty as increasingly subspecialized. In a community hospital, replacing a retiring surgeon who might do a lobectomy on Monday and a valve repair on Thursday can require two hires: a general thoracic surgeon and a cardiac surgeon. A program budgeted for one hire then has to decide which half of the practice it keeps in house and which half it refers out.

When the only cardiac surgeon leaves

In the same study, 80 percent of the surgeons practiced in metropolitan areas, which the authors define as regions of 50,000 residents or more, so hospitals in smaller towns recruit from a smaller group from the start. A program running at the new minimum of one cardiac surgeon has no margin at all. A single retirement or an extended leave leaves the heart team without its required surgeon, and the on-site cardiac surgery program without anyone to staff it, until a replacement holds privileges.

Credentialing sets the pace of a replacement

A cardiac surgeon who accepts an offer cannot operate the following week. The medical staff office verifies training, board certification and case history, a credentials committee recommends privileges for specific procedures, and enrollment with Medicare and commercial payers runs alongside. If the hospital also wants the new surgeon to act as a TAVR operator, the coverage rules add a volume test of their own, at least 20 transcatheter valve procedures a year with 15 of them TAVR, or 40 over two years with 30 of them TAVR, so the case log is checked against the coverage rules as well as against the bylaws.

Each step depends on a committee or an outside body, and the new surgeon counts toward the heart team requirement only once privileges are granted. Programs that open a search as soon as a retirement is first discussed give that sequence room to finish before the departure.

Questions worth asking before joining a small cardiac program

Surgeons considering a community post can turn these staffing rules into direct questions for the program during interviews. It is reasonable to ask how many surgeons hold cardiac privileges today, how many of them are within a few years of retirement, and whether the program’s TAVR operators meet the operator volume with room to spare or just barely. The answers show how much of the structural heart service would rest on the new surgeon’s privileges from the first month. The call schedule follows from the same headcount. Two surgeons covering a cardiac service split night and weekend call, and whenever one takes vacation, the other covers alone. A surgeon weighing two offers can ask each program how it covered the last surgeon’s leave, which shows how that call rotation actually works and how the hospital plans for the next gap. It also helps to ask whether the program has used locum tenens surgeons before. A locum needs privileges too, so a hospital that has already credentialed one knows how long the process takes in its own medical staff office.