Transcatheter Aortic Valve Implantation (TAVI)
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1 Transcatheter Aortic Valve Implantation (TAVI) QEH Registry A Multidisciplinary Team Approach Michael KY Lee 1, LK Chan 1, KC Chan 1, KT Chan 1, SF Chui 1, HS Ma 1, CY Wong 1, CS Chiang 1, P Li 1, CB Lam 1, C Leung 1, MC Chan 1,MY Fan 1, KW Leung 1, HL Cheung 2, CC Ma 2, E So 3, D Fok 3, YF Chow 3, MK Chan 4, W Chan 4, S Chan 4, SF Yip 4, A Cheung 4 Department of Medicine 1, Department of Cardiothoracic Surgery 2, Department of Anaesthesiology 3, Department of Radiology & Imaging 4 Queen Elizabeth Hospital Hong Kong SAR HA Convention 2013
2 Introduction Aortic Stenosis most common valvular heart disease in the elderly 4.6% in adults 75 years of age Once symptomatic, average survival 2-3 years with high risk of sudden death Medical treatment is not effective Surgical AVR is the gold standard TAVI emerges as a viable alternative in inoperable or high risk elderly patients (no open-heart surgery, no cardio-pulmonary bypass)
3 once even minor symptoms occur
4 TAVI Program in QEH Extremely high-risk procedure Multi-disciplinary Heart Team formed in 2009: Interventional Cardiologists Echo Cardiologists Cardiac Surgeons Cardiac Anaesthesiologists Radiologists Cardiac Nurses
5 Queen Elizabeth Hospital Patient Flow HA/Private Hospitals QEH Physicians / Surgeons Overseas QEH TAVI Referral Centre Initial assessment by cardiologists + Echo TEE Coro angio +/- PCI CT angio Heart Team final decision workup for TAVI/SAVR Independent assessment by cardiac surgeons Pre-TAVI case review TAVI Day QEH TAVI Conference (debriefing)
6 Vascular Access
7 31mm valve target at high implant
8 Stepwise deployment of 31mm CoreValve
9 Final position of the CoreValve
10 Hong Kong Experience Dec 2010 Queen Elizabeth Hospital Nov 2011 Prince of Wales Hospital May 2011 HK Adventist Hospital Dec 2012 Queen Mary Hospital
11 Hong Kong Experience Medtronic CoreValve - 45 Edwards Sapien Queen Elizabeth Hospital HK Adventist Hospital Prince of Wales Hospital Queen Mary Hospital TOTAL: 47
12 QEH Registry Characteristic (N = 25) Age (yrs.) Males 16 (64.0%) Procedural Success 100% In-hospital Mortality 0% 30-day Mortality 0% Number (%) or Mean± SD 82.1 ± 4.8 (78 98 years old) 1 subclavian vascular complication treated with stent graft No iliac/femoral vascular complication All femoral wounds closed with Prostar/Proglide x 2 One patient had PCI to LAD done before TAVI, returned for NSTEMI and with redo-pci done, died 3 months after TAVI because of acute coronary stent thrombosis All 25 patients have functionally normal CoreValve with trivial to mild AR, only 1 mild to mod AR
13 Procedure Direct Aortic 0% Subclavian 4.0% 26mm 31mm 29mm 56.0% 4.0% 40.0% Transfemoral 96.0%
14 Procedure & Hemodynamics Comparison of QEH Registry Asia Registry ADVANCE Variables QEH Registry N = 25 Asia Registry N=140 ADVANCE N=996 Procedural success 100% 98.6% 97.8% Serious vascular complications 4% 3.6% NR Hemodynamics Mild PVL 96% 84.3% 87% LVEF 59.8% 61 ± 10% NR AVA (cm 2 ) ± MPG (mmhg) ± NR= Not Reported
15 30-day Outcomes Comparison of QEH Registry Asia Registry ADVANCE Variables QEH Registry N = 25 Asia Registry N=140 ADVANCE N=996 Mortality 0% 2.1% 4.5% Stroke 0% 0.7% 2.9% NYHA NR Pacemaker Implantation 16% 15.7% 26.3% NR= Not Reported
16 30-Day All-Cause Mortality 1. Medtronic Data on File. COR : 18 Fr Safety & Efficacy Study Re-Analysis, August 14, Meredith. VARC-adjudicated Outcomes in Inoperable and High Risk AS Patients. TCT 2010, Washington, DC. 3. Avanzas P, Munoz-Garcia AJ, Segura J, et al. Percutaneous implantation of the CoreValve self-expanding aortic valve prosthesis in patients with severe aortic stenosis: early experience in Spain. Rev Esp Cardiol. 2010;63: Eltchaninoff. French Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 5. Bosmans. Belgian Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 6. Zahn. German Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 7. Ludman. UK Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 8. Petronio. Italian Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France.
17 30-Day Stroke Rate 1. Medtronic. Data on file. COR : 18 Fr Safety & Efficacy Study Re-Analysis, August 14, Meredith. VARC-adjudicated Outcomes in Inoperable and High Risk AS Patients. TCT 2010, Washington, DC. 3. Eltchaninoff. French Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 4. Bosmans. Belgian Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 5. Zahn. German Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 6. Ludman. UK Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 7. Petronio. Italian Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France.
18 Mean Gradient (mmhg) AV Area (cm 2 ) Mean & Valve Area Mean Gradient & Valve Area QEH Registry MPG AVA Baseline 30 days 6 months 12 months Follow-up Visit The PARTNER Trial CoreValve ADVANCE Study
19 QEH Symptom Status (NYHA Class) Changes in NYHA Classification Improved 2 Classes Improved 1 Class Maintained * NYHA: New York Heart Association Functional Classification for Heart Failure Stages (Class I = Best, Class IV = Worst)
20 6-Minute Walk Test Paired-sample t-test: p<0.05
21 Measurement for Quality of Life (SF-12) Physical Component Paired-sample t-test: p<0.05 Mental Component Paired-sample t-test: p<0.05
22 Conclusions TAVI rapid adoption worldwide as a viable treatment option for inoperable or high-risk symptomatic severe AS patients Improve survival with better quality of life (QoL) and functional capacity Multi-disciplinary Heart Team approach Promising short- and intermediate-term outcome results in Hong Kong Long-term outcomes meticulously monitored
23 Surgical AVR The Past TAVI The Future
24
25
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27 Step-wise Deployment
3 years after introduction of TAVI in QEH. Michael KY Lee On Behalf of QEH TAVI Heart Team Queen Elizabeth Hospital Hong Kong
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