How Do I Evaluate a Patient Being Considered for TAVR? Sunday, February 14, :00 11:25 PM 25 min
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1 2016 ASE State of the Art Echocardiography Course Tucson, AZ How Do I Evaluate a Patient Being Considered for TAVR? Sunday, February 14, :00 11:25 PM 25 min 1 M U H A M E D S A R I Ć, M D, P H D D i r e c t o r o f E c h o c a r d i o g r a p h y L a b D i r e c t o r o f O p e r a t i o n s, N o n i n v a s i v e C a r d i o l o g y A s s o c i a t e P r o f e s s o r o f M e d i c i n e N e w Y o r k U n i v e r s i t y L a n g o n e M e d i c a l C e n t e r NYU Leon H. Charney Division of Cardiology
2 Disclosures 2 Speakers Bureau Philips, Medtronic NYU Division of Cardiology
3 Treatment Options for Aortic Stenosis 3 Primary indications for surgical treatment of aortic stenosis SEVERE Aortic Stenosis SYMPTOMS Dyspnea, angina, syncope LV FUNCTION Diminished LVEF NYU Division of Cardiology Severe symptomatic AS irrespective of LVEF Severe AS with diminished LVEF irrespective of symptoms
4 Valve Replacement Options for Aortic Stenosis 4 SAVR Surgical Aortic Valve Replacement (Traditional surgical AVR) TAVR Transcatheter Aortic Valve Replacement same as TAVI Transcatheter Aortic Valve Implantation NYU Division of Cardiology
5 TAVR: PRIMARY INDICATIONS (1)Preferred treatment for inoperable patients (ineligible for SAVR) with severe symptomatic aortic stenosis (2)Alternative treatments for patients with severe symptomatic aortic stenosis who have high SAVR risk NYU Division of Cardiology 5
6 History of TAVR 6 It took a decade to translate the TAVR concept from an animal experiment to a human implant it took another decade to validate TAVR concept in clinical trials Proof of TAVR Concept in Animals First TAVR in Humans PARTNERS Trial of TAVR published TAVR is routine clinical practice NYU Division of Cardiology
7 History of TAVR First Human Implantation in Alain Cribier (b. 1945) French Interventional Cardiologist Performed first TAVR in 2002 (Also first to report percutaneous aortic balloon valvuloplasty in 1986) This first human TAVR: (1) Would not meet current standard indication criteria (Patient had bicuspid aortic valve). (2) Was performed in a manner not performed now (It was done using transvenous, transseptal approach across the mitral valve). NYU Division of Cardiology
8 SURGICAL PROSTHETIC VALVE DEVELOPMENT Trained at Bellevue Hospital, now part of NYU Medical Center 1960 Starr-Edwards mechanical valve 1972 Carpentier-Edwards bioprosthetic valve Albert Starr (b in New York) Miles Lowell Edwards ( ) Alain Carpentier (b in Toulouse)
9 SAVR & TAVR VALVE DEVELOPMENT NYU Leon H. Charney Division of Cardiology 9
10 History of TAVR First Animal Implantation in This first animal TAVR: (1) Was the basis for subsequent balloonexpandable Sapien valve used in humans (2) Was performed in the same manner used in humans now (It was done using transarterial retrograde approach). NYU Division of Cardiology
11 TAVR: The First Wave of Valves 11 NYU Leon H. Charney Division of Cardiology
12 TAVR Prostheses Used in United States 12 Edwards Sapien Valves Balloon-expandable bovine pericardial aortic valve prosthesis Medtronic CoreValves Self-expandable porcine pericardial aortic valve prosthesis NYU Division of Cardiology
13 TAVR Prostheses Used in United States 13 Edwards Sapien Valve Anchoring in the aortic annulus Medtronic CoreValve Anchoring in ascending aorta and LVOT. NYU Division of Cardiology
14 TAVR Prostheses Used in United States 14 Video 1 Video 2 Edwards Sapien Valve Balloon Expandable NYU Division of Cardiology Medtronic CoreValve Self Expanding
15 1 st Wave: What We Have Accomplished 15 NYU Leon H. Charney Division of Cardiology
16 SEVERE AORTIC STENOSIS TEE: Transgastric View NYU Leon H. Charney Division of Cardiology 16
17 SEVERE AORTIC STENOSIS Continuous Wave (CW) Doppler Pulsed Wave (PW) Doppler AORTIC VALVE VTI = 134 cm Vmax = 4.3 m/sec Peak/Mean Gradient 74/43 mm Hg LVOT VTI = 24 cm Vmax = 0.8 m/sec Area 3.14 cm 2 Dimensionless Index = 24 / 134 = 0.18 Aortic Valve Area = 0.6 cm 2 NYU Leon H. Charney Division of Cardiology 17
18 SEVERE AORTIC STENOSIS TREATED WITH SAPIEN TAVR NYU Leon H. Charney Division of Cardiology 18
19 SEVERE AORTIC STENOSIS TREATED WITH COREVALVE TAVR NYU Leon H. Charney Division of Cardiology 19
20 Aortic Valve Gradients Pre & Post TAVR 20 Before TAVR (Severe native valve stenosis) After TAVR (Minimal aortic valve gradients) NYU Division of Cardiology
21 TAVR TREATMENT OUTCOMES NATURAL HISTORY Symptomatic Severe AS Mortality 2-year 50% 5-year 80% Prognosis of severe symptomatic stenosis treated medically is abysmal. NYU Leon H. Charney Division of Cardiology 21
22 1 ST WAVE OF TAVR: WHAT ELSE HAVE WE ACCOMPLISHED? Simplified anesthesia management during TAVR INITIAL TAVR EXPERIENCE General anesthesia SUBSEQUNT TAVR EXPERIENCE Moderate sedation Endotracheal intubation No endotracheal intubation TEE guidance TTE guidance NYU Leon H. Charney Division of Cardiology 22
23 NYU Leon H. Charney Division of Cardiology 23
24 NYU TAVR TEAM NYU Leon H. Charney Division of Cardiology 24
25 CoreValve Deployment 26 NYU Leon H. Charney Division of Cardiology
26 CoreValve Deployed 27 NYU Leon H. Charney Division of Cardiology
27 POST TAVR COMPLICATION: VSD + GERBODE DEFECT NYU Leon H. Charney Division of Cardiology 28
28 POST TAVR COMPLICATION: VSD + GERBODE DEFECT NYU Leon H. Charney Division of Cardiology 29
29 POST TAVR COMPLICATION: VSD + GERBODE DEFECT RA LV to RA Gerbode Jet AV AV RV LV to RV VSD Jet NYU Leon H. Charney Division of Cardiology 30
30 POST TAVR COMPLICATION: MEMBRANOUS VSD + GERBODE DEFECT Membranous Septum Frank Gerbode ( ) American Cardiac Surgeon NYU Leon H. Charney Division of Cardiology 31
31 1 ST WAVE TAVR We have accomplished a lot so what s the problem? NYU Division of Cardiology 32
32 PARAVALVULAR AORTIC REGURGITATION POST TAVR Trivial PVL Marked PVL Potential for Hemolytic Anemia Potential for Hemodynamic Compromise NYU Leon H. Charney Division of Cardiology 33
33 PARAVALVULAR AORTIC REGURGITATION POST TAVR No easy way to grade it VARC II Criteria An expert consensus without empiric validation NYU Leon H. Charney Division of Cardiology 34
34 PARAVALVULAR AR POST TAVR EROA BY 3D ECHO NYU Leon H. Charney Division of Cardiology 35
35 PARAVALVULAR AR POST TAVR IMPACT ON SURVIVAL Higher grades of paravalvular AR portend worse prognosis. Even mild paravalvular AR portends worse prognosis. NYU Leon H. Charney Division of Cardiology 36
36 PARAVALVULAR AR POST TAVR IMPACT ON SURVIVAL Moderate/Severe paravalvular AR Mild paravalvular AR NYU Leon H. Charney Division of Cardiology 37
37 PARAVALVULAR AR POST TAVR MECHANISMS Undersized TAVR Valve Meticulous annular sizing pre- TAVR minimizes this risk. Maldeployed TAVR Valve Reposition existing TAVR or do valvuloplasty or place valve-invalve TAVR Excessive Aortic Root Calcium New TAVR prosthesis designs NYU Leon H. Charney Division of Cardiology 38
38 Annular Sizing 39 NYU Leon H. Charney Division of Cardiology
39 Midsystolic Frames NYU Leon H. Charney Division of Cardiology 40
40 1 0 Generation Edwards Sapien 1 0 Generation Medtronic CoreValve NYU Leon H. Charney Division of Cardiology 41
41 TAVR-RELATED AORTIC ROOT MEASUREMENTS Some interventionalists prefer CT measurements of aortic root over echocardiographic measurements because calcifications interfere with echo but not CT imaging. NYU Leon H. Charney Division of Cardiology 42
42 AORTIC ANNULAR SIZING CT Aortic annular perimeter by CT NYU Leon H. Charney Division of Cardiology 43
43 Edwards Sapien & Sapien XT Medtronic CoreValve NYU Leon H. Charney Division of Cardiology 44
44 AORTIC ANNULAR SIZING 3D TEE NYU Leon H. Charney Division of Cardiology 45
45 Post Dilation for TAVR PVL 46 NYU Leon H. Charney Division of Cardiology
46 BALLOON POST DILATATION ACCENTED MEANS OF REDUCING PVL NYU Division of Cardiology 47
47 Valve-in-Valve For TAVR PVL 48 NYU Leon H. Charney Division of Cardiology
48 1 ST COREVALVE MALPOSITIONED >> PARAVALVULAR AR NYU Division of Cardiology 49
49 2 ND COREVALVE PLACED VIV >> NO MORE PARAVALVULAR AR NYU Division of Cardiology 50
50 New Generation of TAVR Valves 51 NYU Leon H. Charney Division of Cardiology
51 NEW WAVE OF TAVR VALVES (1) Repositionable during delivery (2) Special proximal prosthetic skirt design to prevent PVLs NYU Division of Cardiology 52
52 COREVALVE EVOLUT R NYU Leon H. Charney Division of Cardiology 53
53 SAPIEN 3 NYU Leon H. Charney Division of Cardiology 54
54 DIRECT FLOW NYU Leon H. Charney Division of Cardiology 55
55 DIRECT FLOW NYU Leon H. Charney Division of Cardiology 56
56 DIRECT FLOW NYU Leon H. Charney Division of Cardiology 57
57 PORTICO NYU Leon H. Charney Division of Cardiology 58
58 LOTUS NYU Leon H. Charney Division of Cardiology 59
59 LOTUS NYU Leon H. Charney Division of Cardiology 60
60 EDWARDS CENTERA NYU Leon H. Charney Division of Cardiology 61
61 ENGAGER NYU Leon H. Charney Division of Cardiology 62
62 SYMETIS ACUARATE NYU Leon H. Charney Division of Cardiology 63
63 JENA VALVE NYU Leon H. Charney Division of Cardiology 64
64 Older TAVR Designs Newer TAVR Designs NYU Leon H. Charney Division of Cardiology 65
65 Thank You! 66 New York University Medical Center NYU Leon H. Charney Division of Cardiology
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