Percutaneous Management of Severe AS in Octagenarians. Phillip Matsis FRACP FCSANZ Interventional Cardiologist Wakefield Heart Centre Wellington

Transcription

1 Percutaneous Management of Severe AS in Octagenarians Phillip Matsis FRACP FCSANZ Interventional Cardiologist Wakefield Heart Centre Wellington May 2017

2 Outline Aetiology of AS Natural History of AS Assessment Treatment options TAVI minimally invasive Case The Future.its upon us now!

3 Changing Pattern of Valvular disease in Industrialised Countries Soler-Soler J, Galve E Heart 2000;83:

4 Prevalence of Valvular Heart Disease Nkomo et al. Lancet 2006;368:

5 Prevalence and Incidence of AS in New Zealand

6 Prevalence and Incidence of AS in New Zealand

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9 Assessment

10 Aortic Stenosis - Aetiology Carpentier A et al. (2010) Prosthetic valve selection for middle-aged patients with aortic stenosis Nat. Rev. Cardiol. doi: /nrcardio

11 AS and Valve Morphology According to Age 932 aortic valves excised during AVR for AS 49% had bicuspid aortic valves (Roberts et al. Circ 2005;111: )

12 Bicuspid Aortic Valve Continuing Medical Implementation

13 Progression of AS in Bicuspid Aortic Valves In most cases AS is the consequence of a superimposed degenerative process Development of AS is also linked to cardiovascular risk factors in patients with BAV Hypercholesterolaemia OR 1.8 [ ] Hypertension OR 2.6 [ ] (Chan et al. Am J Card 2001;88:690-3)

14 Progression of Aortic Stenosis: Predictive Factors from Cardiovascular Health Study OR[IC95%] Age (yrs) 2.2[ ] <0.001 Male 2.0[ ] <0.001 Lp(a) 1.2[ ] <0.001 HT 1.2[ ] Smoker 1.4[ ] LDL 1.12[ ] p Stewart et al. JACC 1997;29:630-4)

15 Progression of Aortic Stenosis: Predictive Factors from Cardiovascular Health Study OR[IC95%] Age (yrs) 2.2[ ] <0.001 Male 2.0[ ] <0.001 Lp(a) 1.2[ ] <0.001 HT 1.2[ ] Smoker 1.4[ ] LDL 1.12[ ] p Stewart et al. JACC 1997;29:630-4)

16 Natural History of AS

17 Natural History of AS Ross J, Braunwald E. Aortic stenosis. Circulation 1968; 38(suppl 5):V61-67

18 Natural History of AS

19 Natural History of AS RO. Bonow, and P Greenland Circ 2015;131:

20 Surgical v Medical Treatment of AS Schwarz F et al. The effect of aortic valve replacement on survival. Circulation 1982; 66:

21 Medical Treatment of AS Schwarz F et al. The effect of aortic valve replacement on survival. Circulation 1982; 66:

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24 Transcatheter Aortic Valve Intervention TAVI Percutaneous implantation of aortic valve prosthesis via the blood vessels

25 Pig Heart Tissue Self-Expanding

26 Self-Expanding

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28 Medtronic Evolut R delivery system

29 Balloon expanded

30 Case Mr L-S 86yo Severe AS with exertional SOB and rest angina TIA with R carotid endarterectomy Mild renal impairment Coronary angiogram: severe prox circ lesion Cardiosurgical discussion o o Cardiac surgeons AVR + CABG possible but at high risk Patient should be considered for aortic valvuloplasty, PCI and then interval TAVI

31 Balloon Aortic Valvuloplasty and PCI Procedure

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42 Progress 6 week follow up Excellent symptomatic improvement Referred for TAVI

43 TAVI Self Expanding Valve

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45 Progress Discharged 48 hours post procedure o Mild haematoma No rhythm issues

46 TAVI Results

47 High Risk Intermediate Risk Low Risk Extreme Risk STS Score (%) Mortality (%) Stroke (%) TAVI Medical TAVI Medical TAVI Medical Wellington AS Audit Patients per Risk Group (%) Partner 1B Groups TAVI SAVR TAVI SAVR TAVI SAVR Partner 1A CoreValve PARTNER SURTAVI Notion Mortality and stroke after one year. The vertical bar correlates to the risk group distribution found in the Wellington Aortic Stenosis Audit 2015/16. Partner 1B compared TAVI to medical management. All other trials compare TAVI to open heart aortic valve surgery (SAVR). * Vascular access complications * Pacemaker requirement [Adapted from Tuzcu, Samir, Kapadia, Svensson, JACC 2015, 65(20), 2196].

48 High Risk Intermediate Risk Low Risk Extreme Risk STS Score (%) Mortality (%) Stroke (%) TAVI Medical TAVI Medical TAVI Medical Wellington AS Audit Patients per Risk Group (%) Partner 1B Groups TAVI SAVR TAVI SAVR TAVI SAVR Partner 1A CoreValve PARTNER SURTAVI Notion Mortality and stroke after one year. The vertical bar correlates to the risk group distribution found in the Wellington Aortic Stenosis Audit 2015/16. Partner 1B compared TAVI to medical management. All other trials compare TAVI to open heart aortic valve surgery (SAVR). * Vascular access complications * Pacemaker requirement [Adapted from Tuzcu, Samir, Kapadia, Svensson, JACC 2015, 65(20), 2196].

49 High Risk Intermediate Risk Low Risk Extreme Risk STS Score (%) Mortality (%) Stroke (%) TAVI Medical TAVI Medical TAVI Medical Wellington AS Audit Patients per Risk Group (%) Partner 1B Groups TAVI SAVR TAVI SAVR TAVI SAVR Partner 1A CoreValve PARTNER SURTAVI Notion Mortality and stroke after one year. The vertical bar correlates to the risk group distribution found in the Wellington Aortic Stenosis Audit 2015/16. Partner 1B compared TAVI to medical management. All other trials compare TAVI to open heart aortic valve surgery (SAVR). * Vascular access complications * Pacemaker requirement [Adapted from Tuzcu, Samir, Kapadia, Svensson, JACC 2015, 65(20), 2196].

50 High Risk Intermediate Risk Low Risk Extreme Risk STS Score (%) Mortality (%) Stroke (%) TAVI Medical TAVI Medical TAVI Medical Wellington AS Audit Patients per Risk Group (%) Partner 1B Groups TAVI SAVR TAVI SAVR TAVI SAVR Partner 1A CoreValve PARTNER SURTAVI Notion Mortality and stroke after one year. The vertical bar correlates to the risk group distribution found in the Wellington Aortic Stenosis Audit 2015/16. Partner 1B compared TAVI to medical management. All other trials compare TAVI to open heart aortic valve surgery (SAVR). * Vascular access complications * Pacemaker requirement [Adapted from Tuzcu, Samir, Kapadia, Svensson, JACC 2015, 65(20), 2196].

51 High Risk Intermediate Risk Low Risk Extreme Risk STS Score (%) Mortality (%) Stroke (%) TAVI Medical TAVI Medical TAVI Medical Wellington AS Audit Patients per Risk Group (%) Partner 1B Groups TAVI SAVR TAVI SAVR TAVI SAVR Partner 1A CoreValve PARTNER SURTAVI Notion Mortality and stroke after one year. The vertical bar correlates to the risk group distribution found in the Wellington Aortic Stenosis Audit 2015/16. Partner 1B compared TAVI to medical management. All other trials compare TAVI to open heart aortic valve surgery (SAVR). * Vascular access complications * Pacemaker requirement [Adapted from Tuzcu, Samir, Kapadia, Svensson, JACC 2015, 65(20), 2196].

52 Patient Selection for TAVI Technical o Adequate peripheral vessels for vascular access o Aortic annulus size Patient Factors o Frailty index o Life expectancy >2 years

53 CT Aortogram TAVI Protocol

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55 Frailty Assessment in CVS Care of Older Patients J Am Coll Cardiol. 2014;63(8):

56 Frailty Assessment Tools Katz Score Independence in ADL Edmonton Frailty Score - Mobility score Timed Up and Go Test

57 Patient Selection for TAVI NZ Public Hospital access criteria o Heart team discussion o Surgical candidates but high risk NZ Private Insurance Criteria o Heart team discussion o High risk patients o Intermediate risk patients

58 In 2020 Minimise vascular access complications Minimise long-term pacing requirements Valve durability will be established TAVI indication for low risk patients All patients will be offered a tissue valve either surgically or TAVI Reoperation will be replaced with Valve in valve TAVI o All surgical tissue AVR should be compatible for future Valve in Valve TAVI

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