Severe Aortic Stenosis in Elderly Patients: Surgical Versus Transcatheter Aortic Valve Replacement (TAVR)
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1 Severe Aortic Stenosis in Elderly Patients: Surgical Versus Transcatheter Aortic Valve Replacement (TAVR) James Dralle, MD Chief, Cardiothoracic Surgery AtlantiCare Regional Medical Center
2 Transcatheter Aortic Valve Replacement FDA Approved for High Risk or Inoperable Patients with Aortic Stenosis
3 Aortic Stenosis (AS) Stiff or fused valve leaflets Calcium deposits Valve does not open/ close properly Restricted blood flow to body
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5 Aortic Stenosis: The Facts Occurs in 7 % of people 65 years old or older Progressive disease Heart murmur 50% of untreated people experiencing symptoms die within 2 years
6 Signs & Symptoms of Valvular Heart Disease Syncope - Dizziness or fainting Angina - Chest pain Dyspnea - Shortness of breath at rest or during exercise Chronic cough Bluish skin color, especially fingers & lips Swelling or sudden weight change Enlarged neck veins & liver
7 AtlantiCare Valve Clinic: Interprofessional Heart Team Cardiologist Interventional cardiologist Cardiac Surgeon Radiologist Valve Coordinator Physician Assistant Cardiac Cath Team - Nurses & Radiology Tech Perfusionists Advanced Practice Nurse Cardiac Critical Care & Progressive Care Nurses
8 Valve Clinic: A Team Approach for Diagnosis & Treatment Past Medical History Current Symptoms Medications Physical Assessment echocardiogram Surgical Risk Score Echocardiogram Pulmonary Function Testing CTA Chest Abdomen Pelvis CT Scan Transesophageal Cardiac Catheterization Frailty & Symptom Testing
9 Severe Aortic Stenosis: Treatment Options Surgical Aortic Valve Replacement (SAVR) Transcatheter Aortic Valve Replacement (TAVR) Balloon Valvuloplasty Medical Therapy
10 Surgical Aortic Valve Replacement
11 Sapien Transcatheter Heart Valve
12 Transcatheter Heart Valve Medtronic CoreValve
13 TAVR Implantation Three Approaches Transfemerol Transapical Transaortic *Depends on artery size
14 TAVR Transfemoral Approach
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17 TAVR Transapical Approach
18 AORTIC VALVE REPLACEMENT: COMPARISON OF APPROACHES
19 TAVR BENEFIT VS. RISK Benefit Symptoms improved/resolved Improved Quality of Life Improved mobility Longer life Risk Stroke Arrhythmia/Cardiac Arrest/ Paceaker Bleeding Kidney Failure Infection
20 Post TAVR Care Cardiovascular Unit > Progressive Cardiac Care Unit Home - Support Person(s) essential Rehab - select patients 2-week surgical follow-up 30-day appointment - Valve function & ADLs 1-year appointment - Valve function & ADLs
21 CASE STUDIES
22 Case Presentation 96 yr. Female 101lbs 59 inches AS Symptomatology Near syncope Dyspnea Fatigue HTN PMH HPL Renal insufficiency CR 1.6, GFR 46 CAD Pneumonia L Carotid stenosis (50%)
23 Medications Lasix 20 mg 1 tab every third day Pravastatin 20 mg daily Vitamin C Vitamin D
24 Valve Clinic Evaluation STS Score Mortality 17.3% Stroke 5.4% Prolonged Vent 30.1% Renal Failure 13.7% NYHA Class III Folstein Mini-mental= 26 Normal=23-30 Frailty testing 5 meter walk = 12 seconds (< 6.0 sec normal) Grip strength = 12 kg (normal > 18 kg) KATZ ADLs 4/6 6=Highly dependent 0= very dependent
25 Diagnostic Testing Echo AVA 0.58 cm2 MG 81 mm/hg Jet velocity 5.7m/s EF 60-65% Mild to mod AI Mild MR Mod MS Mild TR TEE Moderate concentric LVH, reduced left ventricular cavity size. EF 65-70% Severe AS, Mild-mod AI. Mild MAC, Mild MR Mild TR Cardiac Cath AVA 0.50 cm2 MG 66 mm Hg PA 60/14 (32) PCWP 23 mm Hg Fick CO/CI 2.58 /1.9 EF 70 % MR Grade 1 LM no significant disease LAD 40% Proximal and ostial LCX 50% proximal RCA 40% ostial, 50% proximal
26 PFTs Predicted Actual % FVC FEV FEV1/FVC Interpretation: Spirometry shows no obstructive dysfunction. Lung volumes show hyperinflation with air trapping. Airway resistance is increased. Respiratory muscle forces are reduced for both inspiration and expiration, indicating weakness of both the diaphragm and skeletel respiratory muscles.
27 CTA Chest, Abdomen & Pelvis ARMC Interpretation: Annular area: 342 mm2 Area derived diameter: 20.8 mm LCA origin: 12.0mm RCA origin: 15.4mm STJ: 2.3cm Sinus of valsalva: 3.1 cm RCIA:6x6mm, REIA 6x7mm, RFA: 7x7mm LCIA:4x6mm, LEIA: 6x7mm, LFA 6x6mm Compression fracture involving T11and the superior endplate. The exact age is uncertain. M2S Interpretation Annulus area 347 mm2 Diameter Min 18.9 mm Max 22.2 mm Mean 20.6 mm LCA Height 12.8 mm RCA Height 16.7 mm Sinus of valsalva 27.2 mm STJ diameter 24.5 mm STJ Height 20.7 mm Femorals: RCIA 6.5 mm, REIA 6.0mm, RCFA 5.5mm LCIA 6.5mm, LEIA 6.0mm, LCFA 5.5mm
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30 CASE 2
31 Case Presentation 73 yr. female 216 lbs 64 inches AS Symptomology Syncope Angina Orthopnea Dyspnea Fatigue PMH HX MI x2 (Most recent Feb 2014) CAD HTN HF Hyperthyroidism Dialysis NIDDM Non-Hodgkin s Lymphoma (radiation to chest) Colon polyps unable to have surgery due to heart problems
32 Medications Plavix 75 mg daily ASA 325 mg daily Synthroid 50 mcg daily Calcium acetate 667 mg BID Paroxetine 20 mg daily Metoclopramide 5 mg daily Pantoprazole 40 mg daily Colace 100 mg BID
33 Valve Clinic Evaluation STS Score Mortality 6.8% Stroke 3.5% Prolonged Vent 31% Renal Failure N/A NYHA Class II Folstein Mini-mental=29 (23-30 =Normal) Frailty testing 5 meter walk =7 seconds (< 6.0 sec normal) Grip strength = 11kg (normal > 18 kg) Katz ADLs 5/6 (6=Highly independent, 0= very dependent)
34 Echo AVA 0.83 cm2 MG 33 mm/hg EF 45% Moderate AI Moderate MR Moderate TR TEE AVA 0.7cm2 MG 41mm/Hg Moderate AI Mild MAC, mild-mod MR Mild TR EF 40-45% Diagnostic Testing Cardiac Cath R/L HC AVA 0.58 cm2 MG 45 mm Hg PA 60/24 (40) PCWP 29 mm Hg Fick CO/CI 4.67/2.39 AV Index 0.3 LM, LCX no significant disease LAD 100% ostial. D1-severe ostial disease. Ramus-50% proximal. RCA-60% prox-proximal to stent. 70% ostial RPL2 w/ filling defect.
35 Viability study Focal perfusion defect involving anterior apex, remainder of myocardium appears viable.
36 FVC: Pred Actual % FEV FEV1/FVC % Interpretation: Normal Spirometry
37 Carotid US Right and left carotids-non-stenotic atherosclerotic plaque noted. Carotid waveforms appear normal.
38 CTA Chest, Abdomen & Pelvis ARMC Interpretation: Aortic annulus: 466 cm2 Distance to left coronary:1.7 cm Distance to right coronary: 1.6 cm Sinus of valsalva: 3cm STJ: 2.2 cm LCIA: 7 mm, LEIA 6.7 mm, LFA 7 mm RCIA: 8.5 mm, REIA: 6 mm, RFA: 7.2 mm M2S Interpretation Annulus Area mm2 Min 18.3 mm Max 22.3 mm Mean 20.3 mm
39 CASE 3
40 Case Presentation 87 yr. Female 139 lbs 63 inches Symptoms Near syncope Dyspnea on exertion Fatigue PMH HTN CAD IDDM DJD
41 Metoprolol 25 mg BID Amlodipine 5 mg daily Insulin 20 units daily Plavix 75 mg daily Aspirin 81 mg daily Diltiazem 120 mg BID Diovan 160 mg BID Atorvastin 10 mg daily Cymbalta 30 mg daily Medications
42 Valve Clinic Evaluation STS Score Mortality 7.9 % Stroke 2.64 % Prolonged Vent 20.0 % Renal Failure % Euroscore II 7.2 % NYHA Class III Frailty testing 5 meter walk = 41.3 sec (< 6.0 sec normal) Grip strength = 9 kg (normal > 18 kg woman) Katz Index of Independence in ADL 4/6 (highly independent = 6/6) Folstein Mini Mental Exam 21/30 (normal = 23-30)
43 PFTs Predicted Actual % FVC Predicted Actual % FEV Predicted Actual FEV1/FVC Interpretation: No obstructive dysfunction. Lung volumes normal except for decreased ERV secondary to body habitus. Diffusion capacity is mildly reduced. Airway resistance is increased. Respiratory muscle forcesare normal for inspiration, but reduced for expiration, indicating skeletal muscle weakness.
44 Diagnostic Testing Echo (TTE) AVA 0.79 cm2 MG 34 mm Hg AoV2 Max 3.8m/s EF % TEE EF % Severe AS, trace-mild AI Mild MAC, Mild MR Mild TR Normal aortic root, mild atherosclerotic plaque descending aorta. Cardiac Cath AVA 0.70 cm2 MG 35 mm Hg PA 27/11 (17) PCWP 13 mm Hg Fick CO/CI 3.3 /1.99 EF 60 % MR Grade 1 Mild mod CAD: RCA - 40% lesion mid right Patent LAD stent, 30% lesion mid and 30% distal LAD LCX-10 % ostial and 30% lesion mid circumflex
45 CTA Chest, Abdomen & Pelvis ARMC Interpretation Calculated area of annulus 344 mm2 Femoral Arteries RCIA 10mm REIA 7mm RCFA 9mm LCIA 1.1cm LEIA 8mm LCFA 9mm M2S Interpretation Annulus Area 355 mm2 Diameter Min 18.6 mm Max 22.4 mm Mean 20.5 mm
46 Thank You
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