RISK PREDICTION IN TAVR. Beyond STS PROM and the Eyeball Assessment

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1 RISK PREDICTION IN TAVR Beyond STS PROM and the Eyeball Assessment

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3 SAVR VS TAVR BIOPROSHETIC OPEN SURGICAL VALVE (SAVR) BIOPROSTHETIC TRANSCATHETER VALVE (TAVR) This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-SA

4 ACC Expert Consensus on TAVR for Adults With Aortic Stenosis Jan 04, 2017 David S. Bach, MD, FACC

5 2017 AHA/ACC FOCUSED UPDATE OF VALVULAR HEART DISEASE GUIDELINE MAR 15, 2017 DAVID S. BACH, MD, FACC Aortic stenosis: The recommendation for either surgical AVR or TAVR among high-risk patients with severe, symptomatic AS (stage D), after consideration by a heart valve team, was changed from Class IIa (LOE B) to Class I (LOE A). After consideration by a heart valve team, TAVR is a reasonable alternative to surgical AVR for patients with severe, symptomatic aortic stenosis (stage D) and intermediate surgical risk (Class IIa, LOE B-R).

6 IMPORTANT THINGS TO REMEMBER ABOUT TAVR RISK ASSESSMENT TAVR is indicated only for patients with severe symptomatic aortic stenosis that have been determined to be at least intermediate high risk for open surgery (SAVR) Determining risk assessment is a shared decision There are standard guidelines for preoperative imaging Preoperative planning is necessary for procedural success Postoperative management and follow up is required

7 CLINICAL DECISION PATHWAY

8 PATIENT SCREENING

9 CALCULATING

10 STS PREOPERATIVE RISK ASSESSMENT (STS-PROM) TOOLS FOR RISK ASSESSMENT EUROSCORE FRAILTY INDEX FUTILITY PROCEDURE SPECIFIC IMPEDIMENTS EYEBALL TEST

11 STS-PROM ONLINE RISK CALCULATOR Based on patient demographics, risk variables and outcomes from the STS cardiac surgery database derived from over 6.5 million procedures performed by over 3800 participating surgeons around the world Predictive of patient mortality and major complications Can be used to assist patient and families for gathering information and decision making Includes variables for atherosclerosis risk factors, vascular, renal, immunodeficiency and pulmonary disease Does not include variables for pulmonary hypertension, hostile chest, liver disease, malnutrition, cognitive dysfunction and frailty

12 EUROSCORE EUROPEAN SYSTEM FOR CARDIAC OPERATIVE RISK EVALUATION 20,000 CONSECUTIVE PATIENTS AT 128 EUROPEAN HOSPITALS MOSTLY LOW TO INTERMEDIATE RISK PATIENTS FAILS TO ACCOUNT FOR LIVER DISEASE, FRAILTY AND HOSTILE CHEST NOT SUITABLE FOR INDENTIFICATION OF HIGH RISK SURGERY PATIENTS

13 FRAILTY CANADIAN STUDY ON HEALTH AND AGING ROCKWOOD FRAILTY INDEX CARDIVASCULAR HEALTH STUDY FRAILTY SCALE EDMONTON FRAIL SCALE KATZ ADL 6 MIN WALK TEST UP AND GO TEST GAIT SPEED

14 ROCKWOOD CLINICAL FRAILTY SCALE

15 WEIGHT LOSS POOR ENERGY WEAKNESS SLOWNESS LOW PHYSICAL ACTIVITY ABILITY TO RISE FROM A CHAIR CARDIOVASCULAR HEALTH STUDY FRAILTY SCALE

16 FRAILTY SCALE COMPARISON

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18 SCORING FRAILTY IN PATIENTS WITH DEMENTIA The degree of frailty corresponds to the degree of dementia. Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal. In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting. In severe dementia, they cannot do personal care without help

19 FUTILITY LIFE EXPECTANCY < 1 YR SURVIVAL BENEFIT < 25% AT 2 YEARS NO GREATER THAN 1 CLASS INPROVEMENT IN NYHA CHF SCORE UNCONTROLLED MALIGNANCY

20 NUTRITIONAL DEFICIENCY BMI < 21 kg/m2 SERUM ALBUMIN < 3.0 UNEXPLAINED WEIGHT LOSS 10 LBS IN ONE YEAR SHORT GUT SYNDROMES UNCONTROLLED INFLAMMATORY BOWEL DISEASE

21 TRACHEOSTOMY CIRCUMFERENTIAL PORCELIN AORTA SEVERE CONGENITAL CHEST WALL MALFORMATIONS PROCEDURE SPECIFIC IMPEDIMENTS AORTOCORNARY GRAFT OR RIGHT VENTRICLE ADHERENT TO POSTERIOR STERNUM RADIATION DAMAGE HISTORY OF BLOOD DISORDERS OR DIATHESES

22 RISK STRATIFICATION 1. Low risk: STS <4% with no frailty, no comorbidity, and no procedure-specific impediments. 2. Intermediate risk: STS 4% to 8% with no more than mild frailty or 1 major organ system compromise not to be improved postoperatively, and minimal procedure-specific impediments. 3. High risk: STS >8%, or moderate-severe frailty, no more than 2 major organ system compromise not to be improved postoperatively, or a possible procedure-specific impediment. 4. Prohibitive risk: Preoperative risk of mortality and morbidity >50% at 1 year, 3 major organ system compromise not to be improved postoperatively, severe frailty, or severe procedure-specific impediments

23 EYEBALL TEST TAVR OR SAVR? SAVR OR TAVR?

24 EYEBALL TEST SAVR OR TAVR? TAVR OR SAVR?

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