TRANSCATHETER AORTIC VALVE IMPLANTATION: PSCC EXPERIENCE DR HUSSEIN ALAMRI PSCC RIYADH

TRANSCATHETER AORTIC VALVE IMPLANTATION: PSCC EXPERIENCE DR HUSSEIN ALAMRI PSCC RIYADH

Available systems: Edwards (TA and TF) and Core valve.

INTRODUCTION 3 4% 0f > 65 y. 30 40% of elderly denied surgery,. TAVI is an alternative.

2009 2011 2011 44 pt 1. Aortic valve area: < 1 cm 2 (<0.6 cm 2 /m 2 ) 2. Aortic valve annulus diameter: 20 mm and 27 mm, 18 mm 24mm 3. Ascending aorta: 43 mm AND 4a. Age 70 yrs OR 4c. Age 65 yrs and 1-2 comorbidities 4b. Logistic ES 15% OR

CONTRINDICATIONS General For transfemoral approach For the transapical approach 1. Aortic regurgitation 2. Aortic annulus <18 or >25 mm for balloon expandable and <20 or >27 mm for selfexpandable devices 4. Bicuspid aortic valve 5. Present of asymmetric heavy valvular calcification 6. Aortic root dimensions >4.5 cms 7. Presence of apical left lf ventricular thrombus 8. Evidence of acute myocardial infarction <30 days 9. Hypertrophic cardiomyopathy 10. Life expectancy <1 year due to non cardiac causes 1. Iliac arteries with severe calcification tortuousity and small diameter (6 9 mm), previous aorto femoral bypass 2. Severe angulation of aorta and atheroma of the outcome andcoaptation coaptation, aneurysmof the abdominal aorta with mural thrombus 3. Presence of bulky atherosclerosis of the ascending aorta and arch 1. Previous surgery of the left ventricle using a patch such as the Dor procedure 2. Calcified pericardium 3. Severe respiratory insufficiency

Age mean 79 y Sex M 52.5% F 47.7% 7% HTN 70% Lipid 77.5% DM 62.5% COPD/CLD 17.5% Prior MI 32.5% CABG 15% CHF 22.5% CR impairment 15% CVA 20% Carotid 25% AF 10% Smoking 5% LM AV distance mean 12.7 mm PVD normal mild 32.5% mod 37.5% mod sever 47.5% sever 10%

120% presentation 100% 80% 60% 40% presentation 20% 0% angina dyspnea II IV CHF syncope

Echo Dilated LV 17.5% LVH mild mod sever AV Ca mild mod sever 77.5% 10% 20% 37.5% mod sever in 80% 42.5% AR mild 52.5% mod 30% mild mod AR 82.5% sever 5% MR mild mod sever 45% 32.5 mod sever MR 42.5% 10% TR mild 22.5% mod 20% mod sever TR 27.5% sever 7.5% EF mean 50% PG MG PAP mean 86.3mmhg 50 mmhg 40mmhg

Cardiac Cath 35% 30% 25% 20% 15% 10% 5% 0% CAD N SVD 2VD 3VD LM PCI CAD

53.00% 52.00% 51.00% 50.00% 49.00% 48.00% 47.00% 46.00% 45.00% Transapical Type transfemoral Type

100% anesthesia 80% 60% 40% anesthesia 20% 0% GA CS

Echo Result 100 90 80 70 60 50 40 30 20 10 0 PG P< 0.0001 MG pre post

Mild AR/PV leak 18 16 16 14 12 10 % 8 6 7 AR/PV leak 4 2 0 0 Mild Moderate sever

Immediate Outcome NO % Edward 36 90% Core 4 10% PV leak. 4 10% success 39 97.5% Death 1 2.5% bleeding 7 16.4% RV perforation 2 5% MI 1 25% 2.5% vascular 4 10% leak 3 7.5% LM compression 2 2.5% Conversion to AVR 2 2.5%

Outcome at 0 6 Months NO % In hospital M 2 5% Post D.C M 2 5% CVA 2 5% PPM 3 7.5% ARF 3 7.5% P.EMB 2 5% PE 6 15.8% Wound infection 2 5% B.transfusion 17 43.6%

6 M 1 Y FU pre post NO 40 25 AR trivial mild 52.5% 23% mod 30% 0% sever 5% 0% MR mild mod sever TR mild mod sever 45% 32.5 10% 22.5% 20% 7.5% 47% 11% 6% 23% 6% 17% EF mean 50% 55% PAP mean 40 mmhg 35 mmhg FC II III I

FU MR 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% pre 6 M no MR mild MR mod MR sever MR

Improvement in MR severity 1.8 1.6 MR Grade 1.4 12 1.2 1 0.8 0.6 P < 0.001 Pre TAVI Post TAVI 0.4 0.2 0

FU TR 60.00% 50.00% 40.00% 30.00% pre 20.00% 6 M 10.00% 0.00% no TR mild TR mod TR sever TR

Complications One patient after transfemoral implantation of Edward Sabien valve, and the patient needed emergency CABG and died after 1 week One patient post transapical TAVI due to coronary embolization (patient died on table )

Case 1 79 y male Euro score 20% AVA 0.5, PG 95, MG 57, EF 60%, AV AM AM distance 11mm Sever AV calcification

12% mortality 10% 8% 6% 4% mortality 2% 0% 30 D 1 y

Freedom from death

No case is easy or straight forward CONCLUSION TAVI can be done with reasonably low M & M, however, we are dealing with very high risk patients, approach should be through multidisciplinary approach. Patient selection remains a learning curve. The trans apical approach is very simple BUT requires a minithoracotomy. The transfemoral approach is technically moredifficult but has advantages if the peripheral complication rate can be minimised and sheath size is reduced This is a major technology breakthrough, it's the future remain to decided. ( like PCI & stents)