TAVR or SAVR: Beyond the STS Score
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1 TAVR or SAVR: Beyond the STS Score Juan Crestanello, MD Division of Cardiac Surgery Lakshmi Prasad Dasi, PhD Department of Biomedical Engineering The Ohio State University Wexner Medical Center 1 Disclosures Dr. Dasi NIH/NHLBI NIH/NIBIB NIH/NCAI AHA Dr. Crestanello Research Grants from: Medtronic Boston Scientific Abbot Vascular 2 1
2 Patient Selection for SAVR vs TAVR Risk Profile STS PROM + Frailty + Other Comorbidities Low Risk Intermediate Risk High Risk Extreme Innoperable Risk SAVR TAVR Moving Beyond Risk -Life Expectancy-Valve Durability Concomitant cardiac disease Mitral valve disease Coronary artery disease Valve and Aortic Root Anatomy Bicuspid Aortic Valve LVOT Calcification Small root-low lying coronary ostia 2
3 Moving Beyond Risk -Life Expectancy-Valve Durability Concomitant cardiac disease Mitral valve disease Coronary artery disease Valve and Aortic Root Anatomy Bicuspid Aortic Valve LVOT Calcification Small root-low lying coronary ostia and Life Expectancy: Longer General Population after Surgical AVR Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 3
4 Surgical Valve Durability Freedom from Structural Valve Deterioration: Surgical AVR -15 years 7 Bourguinion et al. Ann Thorac Surg 15 and Life Expectancy: Longer General Population after Surgical AVR Freedom From SVD: Surgical AVR 8 Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 4
5 and Life Expectancy: Longer General Population after Surgical AVR % 21% 12% 3% 21 REOPERATION Freedom From SVD: Surgical AVR 9 Social Security Life Tables Birkmeyer et al. Ann Thorac Surg TAVR Durability 5
6 TAVR Durability 11 and Life Expectancy: Longer General Population after Surgical AVR 21 HIGHER REOPERATION RATE Freedom From SVD: TAVR 12 6
7 Moving Beyond Risk -Life Expectancy-Valve Durability Concomitant cardiac disease Mitral valve disease Coronary artery disease Ascending aortic aneurysms Other Valve and Aortic Root Anatomy LVOT Calcification Small root-low lying coronary ostia Bicuspid Aortic Valve Moving Beyond Risk -Life Expectancy-Valve Durability Concomitant cardiac disease Mitral valve disease Coronary artery disease Ascending aortic aneurysms Other Valve and Aortic Root Anatomy Annular and LVOT Calcification Small root-low lying coronary ostia Bicuspid Aortic Valve 7
8 Annular and LVOT Calcification LVOT Calcification 15 Valve Underexpansion Paravalvular Leak Annular Rupture Annular and LVOT Calcification Paravalvular Leak - opposing side 16 8
9 Annular and LVOT Calcification Aortic View Annular View Finite element modeling Crimping stores energy into the nitinol valve frame Valve frame does work to push calcified leaflets open 17 Annular and LVOT Calcification Stent conformation over calcification results in flow paths Potential for predictive modeling to optimize Placement Device selection 18 9
10 Annular and LVOT Calcification Computational Fluid Dynamics Simulation 19 Potential to couple fluids simulations with finite element modeling for preoperative planning Moving Beyond Risk -Life Expectancy-Valve Durability Concomitant cardiac disease Mitral valve disease Coronary artery disease Valve and Aortic Root Anatomy Annular and LVOT Calcification Small root-low lying coronary ostia Bicuspid Aortic Valve
11 Small Root Low Lying Coronary Ostia 1-3% of population More common in women 21 Small Root Low Lying Coronary Ostia The flow area for coronary bound flow can be complex due to: Height, calcification, and width Simulations and/or geometrically aligned indices better predict than just height 22 11
12 Small Root Low Lying Coronary Ostia Cylinder CoreValve Portico Device specific variation in leaflet position Possible room for device selection and coronary protection for inoperable patients 23 Moving Beyond Risk -Life Expectancy-Valve Durability Concomitant cardiac disease Mitral valve disease Coronary artery disease Valve and Aortic Root Anatomy LVOT Calcification Small root-low lying coronary ostia Bicuspid Aortic Valve 12
13 Bicuspid Aortic Valve 2-3% of population More common in the young % elderly patients with AS 25 Bicuspid Aortic Valve Asymmetric cusps More calcified Asymmetric calcification More circular annulus Larger Sinuses of Valsalva STJ Ascending aorta 26 Philip et al Catheterization and Cardiovascular Interventions 15 13
14 Bicuspid Aortic Valve Device under-expansion Higher rate of Paravalvular leak Second device Annular rupture Conversion to surgery Improved with newer devices Simulations? Fate of the ascending aorta? 27 Yoon et al JACC 15 Summary So what is beyond STS score? Clinical outcomes Durability Concomitant diseases Mitral, Coronary, Other Valve and Aortic Root Factors LVOT Calcification Low Lying Ostia Bicuspid Directly impacts hemodynamics and valve durability 28 14
15 Acknowledgement WMC Structural Heart Group esp. Jennifer Dollery Doctoral Students: Amir Azimian, Hoda Hatoum, Atieh Yousefi Funding: NIH, DHLRI-Trifit 29 15
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