Patient with low-flow low-gradient aortic stenosis and ischemic cardiomyopathy TAVR and possibly percutaneous revascularization
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1 Patient with low-flow low-gradient aortic stenosis and ischemic cardiomyopathy TAVR and possibly percutaneous revascularization + K Spargias, MD, PhD THV Director Hygeia Hospital
2 Disclosures - Proctor to Edwards Lifesciences, Medtronic - Consultant to Edwards Lifesciences, Medtronic I and the HYGEIA Hospital «Heart Team» have received research and/or travel grants and/or lecture fees from: - Abbott Vascular - Edwards Lifesciences - Medtronic - Boston Scientific HYGEIA Hospital Heart Team Cardiologists: M Chrissoheris, A Halapas, G Kourkoveli, K Papadopoulos, K Spargias CT Surgeons: G Pattakos, N Bubulis, S Skardoutsos, A Tsolakis, S Pattakos Anesthesiologist: I Nikolaou Vascular Surgeons: I Belos, S Kaliafas EP: T Apostolopoulos, S. Kourouklis, L Papadimitriou, G Zervopoulos Radiologists: C Mourmouris, F Laspas Pediatric Cardiologist: A Tzifa RN: E. Dafnomili
3
4 Operative risk stratification and prediction of long term outcomes in LG-LEF AS LV contractile reserve (CR) during dobutamine infusion was defined by an increase in stroke volume of 20% Group I: CR + Group II: CR - Operative risk predictors 1. Lack of CR 2. MPG <20mmHG Circulation. 2003;108
5 TAVI vs. Medical Rx in PARTNER Cohort B LF-LG and LEF Circulation 2013;127
6 TAVI vs. Medical Rx in PARTNER Cohort B LF-LG and LEF Circulation 2013;127
7 Comparison of LVEF recovery in patients with low LVEF after TAVI and SAVR Circulation. 2010;122
8 Comparison of LVEF recovery in patients with low LVEF after TAVI and SAVR Circulation. 2010;122
9 TAVI vs SAVR in Classical LF-LG AS TAVI has also been proved in LF-LG AS vs. Medical Rx and SAVR Some studies suggest better and faster LV function recovery post TAVI TAVI is associated with less PPM
10 Prevalence of Coronary Artery Disease By Age Prevalence of Valvular Heart Disease By Age Circulation 2012;125:e2-e220 AHA Heart Disease and Stroke Statistics 2012 Update Lancet 2006;386:
11 Coronary Artery Disease in TAVR Patients Incidence In pts. undergoing TAVR the prevalence of significant CAD is reported between 44% - 75% EuroInterv 2013; 9: S63
12 1308 consecutive pts. with significant CAD (>50% stenosis) undergoing AVR with or with out CABG between 2001 and 2010 Simultaneous CABG and SAVR reduces risk late mortality J Thorac Cardiovasc Surg 2015;149:451-60
13 Impact of CAD on clinical outcome post TAVR The severity of CAD at baseline has prognostic implications among patients with severe AS undergoing TAVR Baseline SYNTAX score and outcome Bern TAVI Registry EuroInterv 2014; 10: U69
14 Impact of incomplete revascularization on clinical outcome post TAVR Pts. with incomplete revascularization with high residual SYNTAX Score (>14) had impaired long-term clinical outcomes post TAVR Residual SYNTAX score and outcome Bern TAVI Registry EuroInterv 2014; 10: U69
15 Issues connected to Revascularization in AS patients considered for TAVI Assessment of need for revascularization Timing of revascularization in relation to TAVI Completeness of revascularization Coronary protection during TAVI Consideration for future revascularization requirements
16 Exclusion Criteria for CAD in Landmark Trials PARTNER Any therapeutic invasive cardiac procedure performed within 30 days of the index procedure, or 6 months if the procedure was a drug eluting coronary stent implantation PARTNER 2 Any therapeutic invasive cardiac procedure resulting in a permanent implant that is performed within 30 days of the index procedure, unless part of planned strategy for treatment of concomitant coronary artery disease PARTNER 3 No comment Corevalve US High Risk Significant untreated CAD Corevalve Evolut R US Any untreated significant CAD SURTAVI Any percutaneous coronary or peripheral interventional procedure performed within 30 days prior to randomization. Multivessel coronary artery disease with a Syntax score >22 and/or unprotected left main coronary artery
17 No Randomized Trial Data to date
18 N
19 Clinical Outcomes in SURTAVI Based on Revascularization Stratification Patients with SYNTAX score >22 and/or unprotected left main disease were excluded. In patients randomized to TAVR, PCI could be con- current or staged; coronary artery bypass surgery was to be done concomitantly with SAVR. The only significant differences between the groups were: 1. STS risk score for mortality 4.8%±1.7% vs 4.4%±1.5% for no revascularization) 2. Were more likely to be male (65.1% vs 54.2%) Søndergaard et al, JACC 2017, TCT 39
20 Clinical outcomes at 1 year are presented per patients randomization stratification Søndergaard et al, JACC 2017, TCT 39
21 Clinical Outcomes in SURTAVI Based on Revascularization Stratification 1 year All cause Mortality Revasc No Revasc 2 0 TAVI SAVR Søndergaard et al, JACC 2017, TCT 39
22 Clinical Outcomes in SURTAVI Based on Revascularization Stratification 1 year All cause Mortality/Disabling Stroke Revasc No Revasc TAVI SAVR Søndergaard et al, JACC 2017, TCT 39
23 Clinical Outcomes in SURTAVI Based on Revascularization Stratification 1 year Myocardial Infarction Revasc No Revasc 2 0 TAVI SAVR Søndergaard et al, JACC 2017, TCT 39
24 Clinical Outcomes in SURTAVI Based on Revascularization Stratification 1 year Life threatening/disabling bleed Revasc No Revasc 2 0 TAVI SAVR Søndergaard et al, JACC 2017, TCT 39
25 Clinical Outcomes in SURTAVI Based on Revascularization Stratification 1 year Major Vascular Complication Revasc No Revasc 2 0 TAVI SAVR Søndergaard et al, JACC 2017, TCT 39
26 Clinical Outcomes in SURTAVI Based on Revascularization Stratification 1 year Acute Kidney Injury (stages 2-3) Revasc No Revasc 2 0 TAVI SAVR Søndergaard et al, JACC 2017, TCT 39
27 Activation Trial Randomized Controlled Trial; ISRCTN tests the hypothesis of non-inferiority of pre-tavr PCI vs. medical management of significant coronary lesions Will provide further insight into optimal revascularization strategies in pts. with CAD undergoing TAVR
28 Coronary Hemodynamics in Patients With Severe Aortic Stenosis and Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement Ahmad et al, JACC Intv 2018;11:
29 Changes in coronary flow after TAVI 30 vessels, 28 patients PdPa-flow: resting flow over the whole cardiac cycle ifr-flow: resting flow during the wave-period of diastole FFR-flow: hyperemic flow over the whole cardiac cycle Ahmad et al, JACC Intv 2018;11:
30 Changes in systolic coronary flow after TAVI Ahmad et al, JACC Intv 2018;11:
31 Change in fractional flow reserve (FFR) and instantaneous wavefree ratio (ifr) values after TAVI Ahmad et al, JACC Intv 2018;11:
32 116 vessels, 95 patients Yamanaka et al, JACC Interv 2018
33 Yamanaka et al, JACC Intv 2018
34 Simultaneous PCI (with Rota) and TAVI
35 87yo SOB on exertion last 3m New symptoms of unstable angina last week TTE: AVS, AVA 0.8cm 2, MPG 36mmHg, LVEF 45% PAVD (LICA 60%), NIDDM Coroangiography: mlad 90% calcified LE I σε 22.44% STS score 5.57% STS morbitity & mortality 30.63%
36 Severely calcified mlad stenosis
37 mlad PTCA (2x20mm balloon)
38 Rotablation with 1.5mm burr
39 Rotablation result
40 mlad stenting result (2.75x18mm DES)
41 BAV 20mm balloon
42 SAPIEN 3 23mm (+2ml)
43 TAVI final result
44 Staged PCI and TAVI
45 68yo SOB on exertion, multiple admissions for APE CABG 4m ago (LIMA to LAD, RIMA to RCA) Coro: RIMA occlusion RCA PCI 1m ago TTE: AVS, AVA 0.55cm 2, PG 99/65 mmhg, LVEF 50% CRF on dialysis last 4y, PAVD (RICA 50%) LE I 26.4%, STS mortality score 7.4% STS morbidity and mortality σε 25%
46 RCA PCI (3.0x18mm DES)
47 Baseline Aortography
48 TAVI final result (Evolut R 23mm)
49 Emergency PCI (LM) and staged TAVI
50 75yo SOB on exertion last 1y (NYHA III) and CCS II Admitted for UA and angiography showed severe LMS disease Became unstable during angiography and underwent urgent, bail out LMS PCI TTE: AVS, AVA 0.5cm 2, PG 85/50 mmhg, LVEF 60% PAVD (LICA 100%, RICA 50%), HT LE I σε 13.11% STS score 3.22%, STS morbitity & mortality 16.32%
51 Severe LMS disease
52 Emergency LMS PCI
53 LMS PCI final result
54 Staged TAVI 1 week after BAV 20mm balloon
55 SAPIEN 3 23mm (+1ml)
56 SAPIEN 3 Final result
57 Threatened LMS occlusion during TAVI Protection and PTCA
58 80yo SOB on exertion last 1y, orthopnea and PND lately Atypical chest pains 2006 AVR for AVS with Biocor #21 TTE: AVS, AVA 0.7cm 2, PG 76/52 mmhg, LVEF 65% NIDDM, restless leg syndrome, spine surgery x3 Coroangiography: unremarkable LE I 19.6%, STS mortality score 12.2% STS morbidity and mortality σε 43.4%
59
60 Baseline Aortography
61 TAVI with LMS protection (stent in place)
62 SAPIEN 3 20mm implantation
63 Post TAVI aortography
64 TAVI to STJ PTCA
65 Final result
66 Challenging future selective coronary ostial engangement
67 82yo TAVI 2014 (CoreValve 29mm) Recent admission for NSTEMI (mild Troponin rise), ECG rate dependent LBBB, biphasic T waves anterior leads Inf STEMI and Primary PCI in 2013 PAVD, NIDDM, partial nephrectomy for kidney Ca Coronary angiography
68 Baseline Aortography
69 Post TAVI aortography
70 Difficult selective RCA engagement
71 Impossible selective LMS engagement
72 Impossible selective LMS engagement
73 Timing of PCI in relation to TAVR Should we intervene before, during or after TAVR? Nickenig et al 2015
74 Algorithm approach to CAD in the TAVR candidate From the Interventional Section Leadership Council of the ACC JACC Intv 2016;9:2371 5
75 Suggested Clinical Practice till Randomized data becomes available In patients undergoing TAVI, consider staged pre-procedural PCI if: 1. Prognostic disease (>50% LMS or equivalent) 2. >70% stenosis in major vessel if > CCS 2 angina present 3. Presentation with undisputable Acute Coronary Syndrome
76 Timing of PCI and TAVI PCI pre TAVR PCI during TAVR PCI post TAVR Pro Con Pro Con Pro Con Easy coronary access with no prosthesis in place Risk of performing PCI in the presence of Severe AS Reduction of access complications (1 for all) Longer procedural time More stable patient with no AS Potential access / coronary cannulation issues Less risk of ischemia during TAVR Complications not tolerated Less risk of hemodynamic instability and ischemia during TAVR More Volume of contrast agent May be averted in elderly asymptomatic patients Risk of ischemic MACE in the waiting Less AKI risk DAPT post PCI may impact post TAVR bleeding Higher AKI risk
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