Transcatheter aortic valves in aortic regurgitation Gry Dahle Dept of Cardiothoracic- and vascular surgery Rikshospitalet, Oslo University Hospital,

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1 Transcatheter aortic valves in aortic regurgitation Gry Dahle Dept of Cardiothoracic- and vascular surgery Rikshospitalet, Oslo University Hospital, Oslo, Norway

2 Aortic regurgitation Prevalence in Framingham study 4.9%, moderate or severe 0.5% AR Peak incidence in sixth decade Male >female Definition less clear than for AS Still TAVI is off label / not recommended in AR Franzone, A. et al. J Am Coll Cardiol Intv. 2016;9(22):

3 AR patients differ from AS patients Younger patients Etiology: Endocarditis Large root disease Aorta disease Bicuspid geometry Tissue disease Repair must be considered Development of heart failure because of dilated ventricle Need of pacemaker

4 Different groups of patients Pure native regurgitation Following surgery David repair* A-dissection with supracoronary graft** Other surgery on ascendens* Deteriorated bioprostheses Stented Stentless/xenografts Homografts *Some of these may have connective tissue disease and should NOT have any stent treatment **Challenging femoral access due to the dissection

5 Management of AR depending on: Valve morphology Severity of regurgitation Any aortic dilatation Asymptomatic patients require close follow up (LV size and function) Strongest indication for treatment: EF < 50% and/or LVESD > 50 mm AVP and valve sparing aortic surgery is to prefer

6 Management of AR

7 ESC and EACTS new Guidelines 2017 Still many level of evidence C Guidelines

8 Gaps in the evidence

9 Challenges in catheter treatment Planning No calcium markers Big anatomi Landmarks for sizing Possible complications PVL/Migration/Embolization Coronary obstruction Need of pacemaker Positioning in annulus

10 Alternative THV Self expanding with stabilizing arches Self expanding with clipping mechanism Self expandable repositionable Mechanical expandable recapturable Balloon expandable Franzone, A. et al. J Am Coll Cardiol Intv. 2016;9(22):

11 THV used for AR Challenges No calcium markers Big anatomi Landmarks for sizing Self expandable Stabilizating arches Tactile feedback Time for positioning Repositionable (limited) Evolut R Balloon expandable One shot Two needed? Sapien family Possible complications PVL/Migration/Embolization Coronary obstruction Need of pacemaker Positioning in annulus Mechanical expandable Retrievable Resheathable Lotus On hold Engager Jena Acurate Chemical expandable Retrievable Resheathable Direct Flow

12 J-valve, Chinese

13 J Valve TA delivery, AR

14 Repositioning, retrieval, controlled deploy Intra annular level, 18Fr delivery TF.

15 Pure AR, TA Jena now TF Regurgitation No landmarks Feelers out Tactile feedback Well functioning valve

16 Considerations for viv in AR Sizing: always rely on CT reconstruction and NOT labelled inner diameter Cusps may have no calcium The tube/conduit may be very calcified Homograft/xenograft may dilate above annulus plane/suture ring The true annular plane may be above the suture ring Fig. 1 Toronto SPV Screening ID: 140-S338 Fig. 2 Homograft Screening ID: 029-S282

17 Stentless bioprostheses and homografts Implant Techniques for Stentless Bioprostheses and Homografts Stentless Valve Model Manufacturer Specific Implant Technique(s)* Homograft NA Full root, root inclusion, subcoronary (complete or modified) Freestyle Medtronic Full root, root inclusion, subcoronary (complete or modified) 3f Medtronic Subcoronary Variety of implant techniques has to be considered in the planning Toronto SPV * St. Jude Medical Subcoronary SJM Toronto Root St. Jude Medical Full root, root inclusion, subcoronary (modified) Edwards Prima Plus * Edwards Lifesciences Full root, root inclusion, subcoronary Courtesy of Medtronic Homograft

18 Preoperative evaluation homograft/xenograft PS-Tech B.V, Amsterdam The Netherlands Peroperative: Fusion imaging may be useful Treatment option may be open technique with Perceval 3Mensio

19 Symetis Acurate in degenerated homograft AR, no landmark Arches and part of the valve released, tactile feedback Final result

20 Sapien 3 in Freestyle Fast pace Attempt on external marker Sapien in AR: often 2 valves needed Second S3 same size deployed Final result

21 Following, A-dissection Sc graft surgery, initial no AR. 7 years later AR, patient did not want redo sternotomy Transapical TAVI Acurate Symetis L, good haemodynamics Uneventful postoperative course Challenging TF due to the dissection The valve implanted

22 Following A-dissection Initial surgery with sc graft, then developed AR two weeks later (or ignored in first operation) Transapical TAVI Engager 26mm, initially good haemodynamics VSR detected (ischemic) increasing symptoms after one day Observed one month Open redo procedure with patch closure Well functioning aortic valve and no residual VSD Engager Transapical Engager implantation VSR Engager in aortic position in dissected aorta

23 Following David procedure Same technique and panning as for homograft Be aware of coronary reimplantations, height from annulus and possible obstruction Graft may give better support for the cathetyer valve Be aware of this may be patients with connective tissue disease

24 GUCH patient ASD, VSD, double outlet right ventricle, transposition of great arteries and pulmonary atresia, 3 operations before GOBT shunt Reconstruction am Rastelli Aortic root am yacoub The aortic valve was dilated Calcium below for annchoring Processering and 3D print Processering by Rahul Kumar

25 Recorded by Karl Øyri

26 CT follow up

27 Good imaging and planning improve results

28 Conclusions TAVI in AR is still not recommended unless special indications Only one prosthesis has CE approval for AR (Jena) TAVI in AR is challenging but feasible The patients with AR are younger and different from patients with AS, hence durability is to be addressed, and repair to be considered instead of replacement TAVI in AR as redo can be considered in high risk patients

29 THANKS

30 TAVI IS HERE FOR THE FUTURE TAVI SAVR TAVI THANKS