Culprit vs Multivalve Transcatheter Intervention Howard C. Herrmann, MD, FACC, MSCAI John Bryfogle Professor of Cardiovascular Medicine and Surgery Health System Director for Interventional Cardiology Director, Cardiac Cath Labs, Hospital of the Univ of PA Perelman School of Medicine University of Pennsylvania Philadelphia
Typical Patients with Increased Surgical Risk Aortic Stenosis and Mitral Regurgitation Mitral and Tricuspid Regurgitation Aortic Stenosis and CAD HOCM and Mitral Regurgitation Aortic and Mitral (MAC) Stenosis
Philosophy of Culprit vs Multivalve Intervention Cardiac Surgeons ---- Interventional Cardiologists Risk of additional surgery Comparative risk of treating only one lesion versus surgery Risk of not recovering from CPB/surgery if leave residual disease Medical management of 1 vs multiple lesions
Case 1 75 yo woman with h/o rheumatic heart disease AR/MR underwent surgery 2009: bio AVR (#25 Magna pericardial) bio MVR (#29 CE pericardial) Jan, 2017, developed DOE (class II-III), AF, TIAs PH: Type 2 DM Hypothyroidism OSA HTN Mild short term memory loss Frailty (2/4) DCCV/TEE: prosthetic MS (mean grad 9), moderately severe AS (mean grad 28), LV dysfunction (EF 35%) Unable to maintain SR -> warfarin OAC, continued symptoms Referred to Penn CV Surgery
STS Risk Calculation Isolated AV Replacement = 6.9% Isolated MV Replacement = 9.5% What therapy would you offer this patient? 1. Double Re-do Valve Replacement at >10% risk 2. Re-do MVR with plan for staged TAVR in the future 3. TMVR VIV (transseptal) with staged TAVR 4. TMVR VIV and TAVR transapically (one procedure)
Case 1 Echo
Case 1 Now that you have seen the most current echo, what would you recommend? 1. Double Re-do Valve Replacement at >10% risk 2. Re-do MVR with plan for staged TAVR in the future 3. TMVR VIV (transseptal) with staged TAVR 4. TAVR with staged TMVR VIV 5. TMVR VIV and TAVR transapically (one procedure)
Case 1 Procedure 1 #26 Corevalve Evolut R VIV TF, conscious sedation Discharged day #2 TTE: Mean AV grad 21 mmhg DVI 0.40 Trace to mild PVL Mean MV grad 12 mmhg
Case 1 Procedure 2: Baseline imaging
Case 1 Procedure 2: Procedure
Case 1 Procedure 2: Results
Case 2 88 yo man referred in 2015 after presenting with CHF, new AF Class II symptoms on meds (can walk up 1 flight, but symptoms pulling his trash can). No orthopnea, PND. PH: Zenker s diverticulum PUD Hypothyroid Meds: Diltiazem, furosemide, Synthroid, metop, warfarin TTE ordered
Case 2 Echo EF 60% Mild-Mod AS (mean grad 12 mmhg, AVA 1.0 cm2, SVI 27 ml/mm2, mild AR) Severe MR (partial P2 flail with multisegment prolapse, EROA 0.43 cm2, MR vol 72 ml, PASP 40 mmhg, VC 0.45 cm
Case 2 TEE EF 60% Mod AS/mild AR mean grad 12 mmhg AVA 1.0 cm2 SVI 27 ml/mm2 Severe MR (partial P2 flail with multisegment prolapse): EROA 0.43 cm2 MR vol 72 ml VC 0.45 cm PASP 40 mmhg
Case 2 STS Risk: Isolated AVR = 4% Isolated MVR = 7% Isolated MVr = 5% What would you recommend to this 88 yo with severe MR, moderately severe LF AS? 1. AVR and MV repair 2. AVR with MV replacement 3. MV surgery alone and plan TAVR when AS is severe 4. MitraClip with staged TAVR 5. Medical management with plan for future double valve
Case 2 Procedure MitraClip 1
Case 2 Procedure MitraClip 2
Case 2 Follow up Did well for close to 2 years when he developed a recurrent episode of AF and echo demonstrated progression of his AS TAVR work up initiated Echo: Peak/mean aortic grads 86/48 mmhg, AVA 0.8 cm2 Mild-mod MR EF 65% Cath: Significant proximal LAD/diag disease
Case 2 Cath
Case 2 What would you recommend to this 90 yo s/p MitraClip with mildmod residual MR, severe AS and proximal LAD disease? 1. AVR and CABG (STS Risk 5%, frailty = 1/4) 2. TAVR only 3. PCI and TAVR
Case 2 Procedures PCI from right radial artery Synergy 3.0 DES to LAD with angiosculpt of diag TF TAVR under MAC 4 wks later Sapien 3 #26 Minor stroke (double vision) Discharged POD #2 Echo Mean grad 8 mmhg Mild PVL Mild-Mod MR EF 70%
Case 2: 1 month TTE LV EF 60% Peak/mean Aortic gradients = 10 and 6 mmhg Mild PVL Mild MR, mean grad 1.3 mmhg