TAVR Transaortic Approach: New Trends in Aortic Valve Surgery
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1 : New Trends in Aortic Valve Surgery Marc R. Moon, M.D. John M. Shoenberg Chair in CV Disease Chief, Cardiac Surgery Director, Center for Diseases of the Thoracic Aorta Washington University School of Medicine St. Louis, MO USA AATS Cardiovascular Valve Symposium São Paulo, Brazil, Saturday November 21, 2015 Disclosures: NONE
2 MULTIPLE ACCESS OPTIONS Transfemoral Approach Transapical Approach Transaortic Approach
3 Annual TAVR Volume TF vs. ALTERNATIVE ACCESS Wash U (projected) Transfemoral Alternative Access
4 POOR TRANSAPICAL CANDIDATE Severe COPD No previous sternotomy Bleeding Ventricular dysfunction Less pulmonary dysfunction Immunocompromised Significantly EF
5 Myocardial Injury after TAVR LV apex injury Transapical Barbash et al.
6 POTENTIAL ADVANTAGES Mini-sternotomy incision Avoids TAVR-TA risks Bleeding Ventricular dysfunction Less pulmonary dysfunction Preserves the advantages of TA Ease of positioning Avoidance of arch manipulation Can be safely performed in most patients including prior sternotomy
7 TA vs. TAo Wash U.
8 SURGICAL TECHNIQUE Wash U. Ferrari et al.
9 SURGICAL TECHNIQUE Wash U.
10 SURGICAL TECHNIQUE Wash U. TAo Zone Straight shot into the valve Free of calcium ~ 6 cm from the valve
11 SURGICAL TECHNIQUE Wash U. Porcelain Aorta? Use CT to identify Ca ++ -free Zone
12 SURGICAL TECHNIQUE Wash U. TAo Zone Sapien (23-29mm): 5-6 cm CoreValve (all sizes): >6 cm
13 SURGICAL TECHNIQUE Wash U.
14 Mini-Sternotomy vs. Right Thoracotomy Assess relationship between aorta, sternum, and rib cage at the level of the 2 nd rib Distance from rib to aorta % of aorta to the right of the sternum Thoracotomy ok if <6cm and >50% aorta is to the right Vinnie Bapat - London AATS 2013: Minneapolis
15 Mini-Sternotomy vs. Right Thoracotomy Aorta <5cm from sternum but left Aorta on right but > 7 cm deep
16 Mini-Sternotomy vs. Right Thoracotomy Aorta <5cm from sternum but left Aorta on right but > 7 cm deep With a rightward J mini-sternotomy, you can access almost all aortas
17 PREOP CT PLANNING Wash U. Mini-sternotomy in redo Vein & Ao not close to sternum LIMA is lateral, RIMA Ø cross midline
18 SURGICAL TECHNIQUE Wash U. Mini-sternotomy in redo Vein & Ao not close to sternum LIMA is lateral, RIMA Ø cross midline
19 SURGICAL TECHNIQUE Wash U.
20 Transapical vs. Transaortic Outcomes of inoperable pts undergoing transapical and transaortic TAVR Baseline TA Patients (N = 125) TAo Patients (N = 94) p-value Aortic Valve Area cm ± ± Aortic Valve Area Index 0.39 ± ± Mean gradient mm Hg ± ± LV Ejection Fraction % ± ± Days Aortic Valve Area cm ± ± Aortic Valve Area Index 0.93 ± ± Mean gradient mm Hg 8.36 ± ± 3.91 <0.001 LV Ejection Fraction % ± ± PARTNER 2 Substudy ACC 2014: Wash., DC
21 Myocardial Injury after TAVR Transaortic vs. Transapical All pts: Baseline vs mo F/U (45 Tao, 206 TA) Propensity matched (102 pts) Ribiero et al, The Annals of Thoracic Surgery, Volume 99, Issue 6, 2015,
22 Real World Data TVT Registry TA 4,085 pts, TAo 868 pts ( ) Conclusion: Patients undergoing TAo were older, more likely female, with higher STS scores than patients with TA access. There were no risk-adjusted differences between TA and TAo access in mortality, stroke, or readmission rates up to 1 year. p = ATS 2015:100:1718
23 CoreValve Pivotal Trial Alternative access, 150 patients (CoreValve US Pivotal) Extreme high-risk AS with prohibitive iliofemoral anatomy Direct aortic approach (n = 80) Proceudre time 55 ± 40 min PRBCs in 35% Subclavian artery approach (n = 70) Proceudre time 67 ± 53 min PRBCs in 11% AATS 2014: Toronto JTCVS 2014: 148:2869
24 TAVR Alternative Access SURGICAL RESULTS Wash U. Baseline Variable TA (n=87) TAo (n=36) P Variable TA (n=128) TAo (n=113) P BASELINE Age (mean, years) 79 ± 8 79 ± Female gender 29 (33%) 13 (36%) 0.84 Female gender 51 (40%) 67 (59%) STS preoperative risk of mortality 11.1 ± ± Peripheral vascular disease 71 (82%) 29 (81%) 1.00 Age (years) 80.0 ± ± Cerebrovascular disease 33 (38%) 15 (42%) 0.84 Left ventricular ejection fraction (%) 50 ± ± STS risk score, % * 10.9 ± ± Chronic obstructive pulmonary disease 53 (61%) 24 (67%) 0.68 Diabetes 57 (46%) 54 (48%) Diabetes Mellitus 40 (46%) 20 (56%) 0.43 Body mass index 27 ± 6 30 ± Creatinine 1.25 ± ± Renal failure 9 (10%) 5 (14%) Peri-and Post-operative Renal failure 13 (10%) 13 (12%) Intraoperative PRBC use 38 (44%) 8 (22%) 0.04 Surgery time (hours) 2.27 ± ± HTN 118 (92%) 110 (97%) Extubated in OR 68 (78%) 33 (92%) 0.12 Dyslipidemia 120 (94%) 103 (91%) Prolonged ventilation (> 24hours) 7 (8%) 1 (3%) 0.44 Cerebrovascular Accidents 2 (2%) 1 (3%) 1.00 Immunocompromise 11 (9%) 20 (18%) Length of Stay (days) 6.9 ± ± Operative mortality 7 (8%) 1 (3%) 0.44 PVD 98 (77%) 87 (77%) CVD 51 (40%) 40 (35%) 0.507
25 SURGICAL RESULTS Wash U. VARIABLE BASELINE TF (n=179) Alt. Access (n=221) Female gender 83 (47%) 112 (51%) Age (mean, years) 81.7 ± ± STS risk score (%) 9.1 ± ± Peripheral vascular disease 51 (29%) 172 (7%) <0.001 Cerebrovascular disease 39 (22%) 76 (34%) INTRAOPERATIVE Procedure time (hours) 2.3 ± ± Fluoroscopy time (minutes) 21.4 ± ± 7.2 <0.001 Contrast dose (ml) 84.7 ± ± 29.8 <0.001 Any blood product 34 (19%) 104 (47%) <0.001 Extubated in OR 161 (89%) 188 (85%) POST-OPERATIVE Length of stay (mean, days) 5.7 ± ± 5.8 <0.001 Cerebrovascular accident 2 (1%) 4 (2%) day mortality 4 (2%) 15 (7%) year mortality 21 (16%) 16 (10%) P STSA 2015, Orlando, FL
26 IMPACT ON PROVIDER
27 IMPACT ON PROVIDER Radiation exposure: Operator position Imaging equipment specs Amount/location of shielding Study at Wash U. Dosimeters during TAVR (n=81) : TF vs. alternate access Cath lab vs. hybrid OR Disposable radiation shielding pads (randomized) Wash U. Submitted to AATS 2016
28 mrad/min TAVR Transaortic Approach IMPACT ON PROVIDER TF vs. Alternative Access: Fluoroscopy time with TF (20±7 v. 11±3 min, p<0.001) Radiation exposure with AA (15.1 v. 5.5 mrads, p<0.001) Radiation exposure for TF cases in hybrid room (9.0 v. 2.2 mrads, p<0.001) Rad Pads did not decrease exposure (9.4 v. 9.0 mrads, p=0.82) Team Radiation Exposures for TAVR AA -Hybrid OR TF-Hybrid OR TF-Cath Lab Wash U. Submitted to AATS 2016
29 CONCLUSIONS Transfemoral and alternative access approaches remain complementary approaches and have their unique advantages and disadvantages A transfemoral-first strategy has been adopted at most institutions and TF implantation remains the most commonly used approach around the world
30 CONCLUSIONS Transaortic procedures will play an increasing role in the future and overcome some of the problems associated with TA insertion TAVR physicians need to be familiar with all approaches and should tailor the implant strategy to the particular patient
31 Thank you for your attention.
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