TAVI, TMVI, TEVAR, EVAR: The end of standard Cardiovascular Surgery? Perspectives of a Cardiac Surgeon

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1 TAVI, TMVI, TEVAR, EVAR: The end of standard Cardiovascular Surgery? Perspectives of a Cardiac Surgeon Daniel Fink MD Dept. of Cardiothoracic Surgery Shaare Zedek Medical Center Jerusalem, Israel

2 Disclosures Just a plain Cardiothoracic Surgeon KISS Principle( keep it simple s..) I have no conflicts of interest

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4 Historical Background Traditional Aortic Valve Replacement and Open Thoracoabdominal Aneurym Repair are well established and long standing therapies. Both procedures have excellent long term effects with acceptable risk factors. Operative risk is affected by both age and comorbidies( EUROSCORE, STS score). With increase in aged and sicker population CONVENTIONAL SURGERY is being avoided!!!

5 WHAT DO WE DO??? Development of lesser invasive therapies!! Catheter based Valve implantation Endovascular Stent Implantation

6 Transcatheter Valve

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8 Endovascular Stent Grafting

9 TEVAR

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11 Benefits of TAVI Excellent Hemodynamic- low transvalvular gradients!!!! Percutaneous Multiple Applications- Valve in Valve ; Calcified MV native??; Trans Apical & Aortic

12 Paravalvular Leak Drawbacks Pacemaker Requirement Non suitability in BAV COST!!!!!!!!!! DURABILITY??????

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16 Two-Year Outcomes in Patients With Severe Aortic Valve Stenosis Randomized to Transcatheter Versus Surgical Aortic Valve Replacement by Lars Søndergaard, Daniel Andreas Steinbrüchel, Nikolaj Ihlemann, Henrik Nissen, Bo Juel Kjeldsen, Petur Petursson, Anh Thuc Ngo, Niels Thue Olsen, Yanping Chang, Olaf Walter Franzen, Thomas Engstrøm, Peter Clemmensen, Peter Skov Olsen, and Hans Gustav Hørsted Thyregod Circ Cardiovasc Interv Volume 9(6):e June 13, 2016 Copyright American Heart Association, Inc. All rights reserved.

17 Kaplan Meier curves depicting (A) a composite rate of all-cause mortality, all stroke, and myocardial infarction (MI); (B) all-cause mortality; (C) composite rate of all-cause mortality, all stroke, and MI in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) <4%; and (D) composite rate of all-cause mortality, stroke, and MI in TAVR and SAVR patients with STS-PROM 4%. Lars Søndergaard et al. Circ Cardiovasc Interv. 2016;9:e Copyright American Heart Association, Inc. All rights reserved.

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19 From: Transcatheter Aortic Valve Replacement in Europe: Adoption Trends and Factors Influencing Device Utilization J Am Coll Cardiol. 2013;62(3): doi: /j.jacc Figure Legend: TAVR Adoption in Europe (A) Cumulative transcatheter aortic value replacement (TAVR) implants in 11 Western European nations between 2007 and (B) TAVR implants per annum and percentage annual increase (solid line). Date of download: 9/7/2016 Copyright The American College of Cardiology. All rights reserved.

20 From: Transcatheter Aortic Valve Replacement in Europe: Adoption Trends and Factors Influencing Device Utilization J Am Coll Cardiol. 2013;62(3): doi: /j.jacc Figure Legend: TAVR Implants per Million Population in the Study Nations TAVR implant dynamics in the study nations between 2007 and (A) TAVR implants per million population. (B) TAVR implants per million population age 75 years. Broken line represents mean. Abbreviation as in Figure 1. Date of download: 9/7/2016 Copyright The American College of Cardiology. All rights reserved.

21 Cases TAVI vs. savr in Israel surgical AVR TAVI Cost per case: savr 15,480 TAVI 48,000

22 Number of procedures surgical AVR TAVI

23 (%) Operative Mortality surgical AVR TAVI

24 Is this the end of savr?

25 Figure 2. University of Alabama at Birmingham isolated aortic valve replacement volume from 2009 through SAVR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement. James E. Davies Jr., William W. McAlexander, Mark F. Sasse, Massoud A. Leesar, Spencer J. Melby, Satinder P. Singh, Lindsey B. Jernigan, Oscar J. Booker, Oluseun O. Alli Impact of Transcatheter Aortic Valve Replacement on Surgical Volumes and Outcomes in a Tertiary Academic Cardiac Surgical Practice Journal of the American College of Surgeons, Volume 222, Issue 4, 2016,

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27 savr in Transcatheter Era

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32 Sutureless Tissue Valves

33 Benefits of Sutureless Valves Excellent Hemodynamics Easy Deployment Minimally Invasive Technique Short CPB Durability? Costs- lower than TAVI BEST OF ALL WORLDS

34 Minimally Invasive Aortic Valve Replacement( MIAVR)

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39 ENDOVASCULAR REPAIR- Advantages Minimally Invasive Less Morbidity & Complications LOS

40 Disadvantages Suitabilty- Proper Landing Zones; CTD Endoleaks Migration & Graft Collapse Durability?

41 Author, Year Fenestrated/Branched Thoracic Endovascular Aneurysm Repair Numbe r of Patient s Mortalit y Paraplegia and Paraparesi s Renal Failure Technical Success Endoleak Re- Intervention Roselli 2007 Haulon 2009 Verhoeven 2009 Guillou 2012 Kitagawa 2013 Oikonomo u

42 Open Repair of Thoracoabdominal Aneurysms Author, Year Svennson 1993 Number of Patients Extent 1 and 2 Mortality Paraplegia and Paraparesis Renal Failure 1, Safi , NA Coselli , Acher Girardi

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44 Endovascular Repair- Recommendations Acute Complicated Type B Aortic Dissection Blunt Traumatic Aortic Injury Penetrating Aortic Ulcers Ruptured Descending Thoracic or TAA- high risk

45 Avoid CTD Mycotic Aneurysms Infected Grafts Aortic Fistulae Ascending Aorta & Arch???? / Type A Dissections?

46 HYBRID

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48 Indications for transcatheter aortic valve implanta TAVIshouldonlybeundertakenwithamultidisciplinary heartteam including cardiologistsandcardiacsurgeonsandotherspecialistsifnecessary. Class I Level C TAVIshouldonlybeperformedinhospitalswithcardiacsurgeryon-site. I C TAVIisindicatedinpatientswithseveresymptomaticASwhoarenotsuitablefor AVRasassessedbya heartteam andwhoarelikelytogainimprovementintheir qualityoflifeandtohavealifeexpectancyofmorethan1yearafterconsideration oftheircomorbidities. TAVIshouldbeconsideredinhighriskpatientswithseveresymptomaticASwho maystillbesuitableforsurgery,butinwhomtaviisfavouredbya heartteam basedontheindividualriskprofileandanatomicsuitability. «In the absence of a perfect quantitative score, the risk assessment should mostly rely on the clinical judgement of the heart team, in addition to the combination of scores.» I IIa B B European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).

49 High Surgical Risk? Decision between TAVI and AVR? EuroScore 20% STS score > 10% Fraility Chest radiation Porcelain aorta Re-operation

50 Conclusions TVR, TEVAR, EVAR- established and effective therapies Indications, Durability, Costs are evolving issues that need further studies. Designated Multidisciplinary Heart & Aortic Team are probably the most effective tool to develop the future applications of these technologies and establishing practice guidelines. RCT and real life registries are essential to determine long term results Extension of TVR to other Heart Valves is still unknown

51 CONCLUSIONS Sutureless Valves and Minimally Invasive Surgery is a promising evolving option that may further extend the pool of patients for Surgical Valve Replacement Hybrid approaches, Improved Stent Graft Technologies ( Branched Grafts) may be the future!! SURGEONS MUST MASTER CATHETER BASED SKILLS!!!( cath or perish!!!)

52 THANK YOU!