Aortic Stenosis Background and Breakthroughs in Treatment: TAVR Update
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1 Aortic Stenosis Background and Breakthroughs in Treatment: TAVR Update Howard J Broder MD Interventional Cardiology DaVita Medical Group/ Healthcare Partners Cardiology
2 Disclosures for Howard J Broder MD As of 2017 I speak and proctor for Abiomed Medtronic
3 Aortic Stenosis- Overview Aortic Stenosis is a common finding in the elderly, and is associated with significant morbidity and mortality. The presenting symptoms are often referred to as the triad of symptoms- Angina/ Dyspnea/ Syncope These are often the presenting symptoms of an inpatient hospitalization. Additionally, the finding of Aortic Stenosis may be a secondary or contributing factor to another reason for hospitalization. Once identified, expeditious evaluation and treatment is recommended.
4 Aortic Stenosis- Prevalence Prevalence of 12.4% in the >75 y/o population corresponds to 2.7 million people in North America. 540,000 are severe/ symptomatic. 40% do not get SAVR. With expected increases in life expectancy, this will increase to 800,000 by 2025 and 1.4M by From: Aortic Stenosis in the Elderly: Disease Prevalence and Number of Candidates for Transcatheter Aortic Valve Replacement: A Meta- Analysis and Modeling Study
5 Aortic Stenosis- nonreferral for AVR
6 Aortic Stenosis- reasons for nonreferral
7 Natural History of Symptomatic AS
8 Treatment of AS is effective
9 The first TAVR in man was performed in Rouen France in 2002 by Alain Cribier (Trained at Cedars Sinai) The first cases were actually done with a transseptal approach before the devices were modified for a retrograde aortic approach Cribier was instrumental in devoloping the Balloon Expandable Valves Self-Exanding Valves were developed contemporaneously To date worldwide there have been >200,000 TAVR implants TAVR Genesis
10 TAVR Genesis- Balloon Expandable vs Self Expanding:
11 The Partner Trial was the first RCT designed to establish the safety and efficacy of TAVR in comparison to Standard (Med Rx) and SAVR. Initiated in 2007 Divided into two parts (Inoperable A, and High Surgical Risk B) TAVR- Building a Body of Evidence: Partner Trial
12 Partner A results: Inoperable Patients TAVR vs Med Rx
13 NYHA Class and Valve Performance
14 Partner B: High Risk Patients All Patients (TF and TA) Transfemoral Access Only
15 Partner B: High Risk Patients
16 TAVR- Building a Body of Evidence- CoreValve Pivotal CoreValve was primarily a European Valve with CE Mark. The US Pivotal Trial started later than Partner. Randomization to Med Rx in Extreme Risk was no longer thought to be ethical.
17 CoreValve Pivotal Trial (TAVR vs SAVR)
18 CoreValve Pivotal Trial
19 CoreValve Pivotal Trial
20 CoreValve Pivotal Trial
21 CoreValve Pivotal Trial
22 And now the bad news for SAVR
23 TAVR- State of the Art (S3) TAVR devices have become smaller and more precise, allowing for better, more reliable and reproducible deployments, and reduced vascular complications. Notable on the Sapien 3 is the smaller sheath size (Expandable E-Sheath). Distal flexing of the catheter can allow for a more coaxial deployment. Fine tuning adjustments can now be made via a dial on the delivery catheter allowing for millimeter corrections. Additionally a skirt is used to reduce paravalvular leak.
24 TAVR- State of the Art (S3)
25 TAVR State of the Art: S3
26 TAVR State of the Art: S3
27 TAVR- State of the Art (Evolute) Lower profile (14 fr) Recapturable/ Repositionable (at up to 80% deployment) Reduced PPM Reduced Paravalvular Leak
28 Evolute CE Mark Study
29 TAVR- State of the Art (Evolute)
30 TAVR- State of the Art (Evolute)
31 74 y/o with Progressive SOB/ Edema. Hx CAD/ CABG/ PPM Cirrosis/ COPD with active EtOH and Tob AS Case1
32 AS Case 1
33 AS Case 1
34 AS Case 1
35 AS Case 1
36 AS Case 1
37 76 y/o woman with progressive dyspnea and Edema. Hx of Pulmonary HTN. Colon Ca dx within the past year. On Intermittent Chemotherapy. AS Case 2
38 AS Case 2
39 AS Case 2
40 AS Case 2
41 AS Case 2
42 AS Case 2
43 Bioprosthetic Valve Degeneration 84 y/o gentleman with a 12 yr old bioprosthetic valve intially placed for Severe Aortic Stenosis. 23 mm Edwards Perimount Valve Class 3-4 NYHA class EF 35% (dropping) Frail (poor candidate for redo sternotomy) Large ascending thoracic aorta
44 Bioprosthetic Valve Degeneration
45 Bioprosthetic Valve Degeneration
46 Bioprosthetic Valve Degeneration
47 AS Case 3 79 y/o with severe back pain/ radiculopathy with spinal stenosis. Needed urgent back surgery. Found to have Severe AS by echo. Mild CAD by Cath BAV was done with gradient dropping from 40 mmhg to 20 mmhg and AVA increased from 0.7 to 1.0. Pt had uneventful surgery and was brought back for TAVR
48 AS Case 3
49 AS Case 3
50 Thank You
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