Prof. Dr. Thomas Walther. TAVI in ascending aorta / aortic root dilatation
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1 Prof. Dr. Thomas Walther TAVI in ascending aorta / aortic root dilatation
2 nn AorticStenosis - Guidelines
3 TAVI and aortic aneurysm? Few data published.
4 EJCTS 2014;46:228-33
5 TAVI and aortic aneurysm? Few data published. Fixation?
6 Fixation of TAVI prostheses Annular fixation (+) Ascending aortic fixation Leaflet fixation
7 Fixation of TAVI prostheses in aortic aneurysm Annular fixation (+) Ascending aortic fixation Leaflet fixation
8 TAVI - different conditions straight - forward moderate calcifications, symmetric distribution Variable / intermediate excentric calcifications, short coronary distance, access issues Hostile: Aortic stenosis + aortic aneurysm
9 Pt. example courtesy J Kempfert, Berlin => 24.5mm annulus, TF S3 26mm
10 Pt. example Little calcification, severe AR significant aortic aneurysm > 6cm STS 8.8, age 88y, severe dyspnea Strong pt. request for TAVI courtesy J Kempfert, Berlin
11 Pt. example => conversion to conventional surgery, good outcome courtesy J Kempfert, Berlin
12 Valvular Heart Dis GL Eur Heart J. 2017;38: Eur J Cardiothorac Surg. 2017;52:
13 Valvular Heart Dis GL Eur Heart J. 2017;38: Eur J Cardiothorac Surg. 2017;52:
14 Valvular Heart Dis GL Eur Heart J. 2017;38: Eur J Cardiothorac Surg. 2017;52:
15 TAVI and aortic aneurysm Pts present usually with larger annulus => risk of paravalvular leak Irregular valve configuration
16 AS and aortic aneurysm Sizing charts Annulus size Sapien / / Corevalve Evolut R Acurate neo 23/ / S S S S/M M M/L L L Portico 23 23/ / / Lotus / / => larger devices required
17 Isolated savr / TAVI in Germany
18 TAVI imaging - assessment
19 Valve selection criteria (a) Clinical condition Potential valves Symetric calcification Heavy calcification Excentric calcification Bicuspid valve LVOT calcium Any valve Any, balloon expandable or self expandable, consider radial force Any, balloon expandable or self expandable Sapien, eventually Lotus Self expandable > balloon expandable Avoid too much oversizing / dilatation Careful positioning
20 Valve selection criteria (b) Clinical condition Potential valves Short coronary distance Narrow aortic sinuses Narrow sinotubular junction Mitral prosthesis in place repositionable valve (self expandable) vs. balloon expandable repositionable valve (self expandable) vs. balloon expandable Subcoronary valve (Sapien, Lotus) Repositionable valve Guidewire?
21 Valve selection criteria (c) Application system diameter Arch tortuosity / calcification vs. application system flexibility Aortic aneurysm Access vessels Access: TF, TA, alternative
22 Patient risk profiles comorbidities e.g. dialysis s/p CABG Low EF Pulmonary hypertension Porcelain aorta Frailty Heart Team Decision: Technical aspects (calcifications etc.) Intermediate risk Low risk age
23 Valvular Heart Dis GL Eur Heart J. 2017;38: Eur J Cardiothorac Surg. 2017;52:
24 Randomized trials TAVI vs. savr High risk and Intermediate risk
25 Trials in perspective What patients are included? Intermediate risk: PARTNER II, SURTAVI Age ~ 80yrs., STS score 4-5% Low risk (by STS score) : PARTNER III (1yr data ACC 2019), COREVALVE low risk, NOTION, UK all comers, DEDICATE (STS >1 / 2%), etc. Patient age? Comorbidities?
26 Ongoing clinical trials in low risk pts. Rogers T et al.:
27 Trials in perspective
28 Patients at low surgical risk undergoing isolated interventional or surgical aortic valve implantation: in-hospital data and one-year results from the German Aortic Valve Registry (GARY). Raffi Bekeredjian 1, Ümniye Balaban, Sabine Bleiziffer, Timm Bauer, Stephan Ensminger, Christian Frerker, Andreas Beckmann, Helge Möllmann, Hugo A. Katus, Thomas Walther 1 University Hospital Heidelberg and Robert-Bosch Hospital Stuttgart European Heart Journal 2018, accepted
29 Patient selection All Patients SAVR: TA TAVI: 2944 TV TAVI: SAVR: TA TAVI: 949 TV TAVI: Exclusion: Patients SAVR+CABG Patient with TAVI + PCI Patients with STS 4% Patients with endocartitis Patients with missing relevant data Double entries European Heart Journal 2018, accepted
30 Patients All (n=20549) SAVR (n=14487) TAVI (n=6062) p value Age (years) ± ± ± 5.63 < Gender Male (62.9 %) 9230 (63.7 %) 3689 (60.9 %) Female 7630 (37.1 %) 5257 (36.3 %) 2373 (39.1 %) BMI (kg/m²) ± ± ± 4.35 < Creatinine 0.98 ± ± ± 0.29 < Previous MI 1296 (6.3 %) 634 (4.4 %) 662 (10.9 %) < Previous PCI 2760 (13.4 %) 1112 (7.7 %) 1648 (27.2 %) < Permanent Pacer 974 (4.8 %) 471 (3.3 %) 503 (8.4 %) < Permanent ICD 181 (0.9 %) 98 (0.7 %) 83 (1.5 %) < Atrial Fibrillation 2951 (14.4 %) 1810 (12.5 %) 1141 (18.8 %) < Mitral Regurgitation (13.6 %) 1638 (11.3 %) 1153 (19.0 %) < Previous Cardiac Surgery 1627 (7.9 %) 842 (5.8 %) 785 (13.0 %) < EF (%) ± ± ± < Hypertension (82.2 %) (80.2 %) 5206 (86.9 %) < Pmean (mmhg) ± ± ± < Neuro Dysfunction 1778 (8.7 %) 961 (6.6 %) 817 (13.5 %) < COPD 1661 (8.1 %) 1130 (7.8 %) 531 (8.8 %) Pulmonary Hypertension 1182 (5.8 %) 535 (3.7 %) 647 (10.7 %) < Diabetes 4114 (20.0 %) 2818 (19.5 %) 1296 (21.4 %) Euro-Score 7.98 ± ± ± 8.30 < STS-Score 2.11 ± ± ± 0.72 < European Heart Journal 2018, accepted
31 Results - Unadjusted Data Survival Rate for Patients SAVR vs. TAVI without Propensity Score Adjustment (survival rates and 95% confidence intervals) TAVI SAVR In-hospital survival (%) % (98.14 %, %) % (98.28 %,98.68 %) 30-days survival (%) 12-months survival (%) % (97.72 %, %) % (98.08 %, %) % (89.22 %, %) % (94.80 %, %) European Heart Journal 2018, accepted
![Results - with Propensity Score adjustment SAVR and TAVI - IH Survival SAVR and TAVI - 30-Days Su SAVR and TAVI - 1-Year Surv Proportion surviving [%] 100 80 60 Proportion surviving [%] 100 80 60](/docs-images/95/122509355/images/32-0.jpg "Proportion surviving [%] 100 80 60 40 40 40 20 20 20 0 SAVR TAVI 0 SAVR TAVI 0 SAVR TAVI 0 30 60 120 180 0 30 0 30 60 120 180 240 300 365 Time (Days) In-hospital survival (%) Time (Days) 30-day")
32 Results - with Propensity Score adjustment SAVR and TAVI - IH Survival SAVR and TAVI - 30-Days Su SAVR and TAVI - 1-Year Surv Proportion surviving [%] Proportion surviving [%] Proportion surviving [%] SAVR TAVI 0 SAVR TAVI 0 SAVR TAVI Time (Days) In-hospital survival (%) Time (Days) 30-day survival (%) Time (Days) 12-months survival (%) TAVI ( 6,062) savr (14,487) p-value European Heart Journal 2018, accepted
33 TAVI results have significantly improved due to: Patient screening and selection (exclude aortic aneurysm) Experience and skills of the Heart Teams Technical developments: TAVI valves and application systems
34 TAVI and aortic aneurysm TAVI is routine in elderly patients, high, intermediate and low risk The majority of TAVI pts does not present with aortic aneurysm Aortic aneurysm will usually be treated in younger pts. (Heart Team recommendations)
35 Ascending aortic endografts Hybrid supracoronary endografts Branched endografts High Risk pts. Factors to consider: - risk of stroke - retrograde dissection - kinking - unclear sealing zone - proper alignment required - etc. vascularnews Feb 2017
36 Branched aortic arch stent grafts Zenith TAG Valiant Mona LSA Nexus Ascending thoracic device Long KN et al.: Endovascular today, Nov 2016, 15:66-70
37 Endovascular aortic repair: Challenges: Anatomy / shape of ascending aorta / arch Angulation of great vessels Blood flow dynamics and shear forces Heart beat variability, respiratory cycle variability Coronary artery anatomy and position, aortic valve
38 Future developments Branched ascending aorta / aortic arch stent graft with consecutive TAVI Transcatheter Bentall prostheses? Custom made? High risk / inoperable pts.
39 Endovascular aortic repair + TAVI Imaging, sizing, selection Custom made solutions for individual patients Complex trials
40 Conclusion TAVI Selection, Experience, Technical developments lead to excellent outcomes TAVI experience in pts with aortic aneurysm is very limited specific hybrid prostheses / procedures will be developed, individual therapeutic decisions required
41 Thank you!
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