Surgical options for aortic stenosis F MAISANO
Dec 02, 2014
Surgical options for aortic stenosis
Surgical options for aortic stenosis
F MAISANOF MAISANO
Evolving scenario of valve diseseEvolving scenario of valve disese
Aging / Increased life expectancy
Changing style of life Quality of life over longevity Productivity Esthetic appearance
Circulation of information Patients awareness Referral pattern
Limited resources / cost containment
AVR: state of the artAVR: state of the art
about 300.000 operations/yr
More than 40 years of clinical experience
Prostheses are reliable
Predictable and low risks
Long term results available
STS DATABASESTS DATABASEAVR
n 32,968
Mortality 4.0%
Stroke 1.5%
Prolonged Ventilation 7.07%
Reoperation 4.12%
Renal Failure 3.7%
MedPAR DataMedPAR Data
Long term OutcomesLong term Outcomes
Eichinger et al Annals thorac Surg 2008
Durability Survival
TAVI: a new tool for the high risk patients TAVI: a new tool for the high risk patients
Aortic valve surgery in the era of TAVIAortic valve surgery in the era of TAVI
TAVI as a complementary procedure for patients with contraindications Clinical Technical
TAVI as an alternative procedure High risk Moderate risk Low risk
AVR in the context of TAVI Prosthesis choice timing
Technical contraindicationsTechnical contraindications
Previous chest radiationPorcelain aortaMultiple previous sternotomies (esp. with open grafts)
Clinical contraindicationsClinical contraindicationsAge
Euroscore, STS score
Severe comorbidities Liver failure Renal failure (dialisis) COPD Neoplasia
frialty
30% of elderly patients are denied surgery30% of elderly patients are denied surgery
Age and mortalityAge and mortality
Euroscore logistic risk for valve surgery
assuming no comorbidities
Euroscore logistic risk for valve surgery
assuming no comorbidities
Aging epidemicsAging epidemics
According to the EC, the number of european citizens aged 75yrs or more is going to be 64M in 2025
x 4 x 7
IIASA, committee of the ECC, 2007
Prevalence of valve disease: AS is epidemic in the elderlyPrevalence of valve disease: AS is epidemic in the elderly
Nkomo et al , Lancet 2006
Risk benefit analysis in the elderlyRisk benefit analysis in the elderly
Evaluation of operative riskEvaluation of operative risk
Risk Operative mortality Morbidity
• Short term • Long term
Benefit• Survival• Quality of life
Common comorbidities in older patientsCommon comorbidities in older patients
Condition implications
Renal dysfunction Exacerbated by diuretics and ACE inhibitors
Chronic lung disease Contributes to uncertainty about diagnosis /volume status
Cognitive dysfunction Interferes with dietary, medication, activity compliance
Depression , social isolation
Worsen prognosis, interferes with compliance
Postural hypotension, falls Exacerbated by vasodilators, diuretics, blockers
Urinary incontinence Aggravated by diuretics, ACE inhibitors (cough)
Sensory deprivation Interferes with compliance
Nutritional disorders Exacerbated by dietary restrictions
Polypharmacy Compliance issues, drug interactions
Frailty Exacerbated by hospitalization; increased fall risk
How do you define debility or fraility ?How do you define debility or fraility ?
•Same age and predicted risk•One passes the “eyeball test”; one doesn’t•Fraility Index
Frailty of the elderlyFrailty of the elderly
Reduction of organ reserve Reduced resistance to
injury Reduced adaptability
Reduced physical activityReduced neurocognitive functionDepression
High to moderate riskHigh to moderate riskRisk of surgery
Risk of TAVI
Aortic Valve SurgeryPredictive Risk AlgorithmsAortic Valve SurgeryPredictive Risk Algorithms
STS
EuroSCORE (additive)
EuroSCORE (logistic)
Ambler (UK)
Northern New England
New York State
Providence Health System
Problems with Risk AlgorithmsProblems with Risk AlgorithmsAll risk algorithms are based on operated patients and don’t factor in “inoperable “ patients
Outcomes other than mortality are not predicted, e.g., stroke, discharge disposition, QoL
Many risk variables not included
Variables Not Included In Risk Algorithms In Patients Undergoing AVR Variables Not Included In Risk Algorithms In Patients Undergoing AVR
Previous chest radiation Oxygen dependence Reoperative patients with open grafts Previous tissue valve replacement Porcelain aorta Advanced liver disease/cirrhosis Degenerative neurocognitive disorders- Alzheimer’s Frailness or debility
Euroscore overestimates the actual risk in the high risk populationEuroscore overestimates the actual risk in the high risk population
Osswald B, et al. European Heart Journal (2009) 30, 74–80
Leontyev et al Ann Thorac Surg 2009
Risk of TAVIRisk of TAVIAscending aorta aneurysm
Uneven or massive valve calcification
Bicuspid valve
Previous mitral valve prosthesis
Access issues
Severe renal failure
Bicuspid vs tricuspid valveBicuspid vs tricuspid valve
Bicuspid Aortic ValveBicuspid Aortic Valve
Valve area and calcium detectionValve area and calcium detection
TAVI screeningTAVI screening
3232 di 22 di 22
Valve Team Hsr
Nov 2007-May 2009
82 TAVI
69 Transfemoral approach
10 Transapical approach
3 Trans-subclavian approach
Patient baseline clinical characteristics (n=82)
Procedural outcomes (n=82)
Survival
Actuarial survival at 12 months: 88.1±4.3%
April 9, 2023Data Snapshot37
The SOURCE Registry Cohort One
TF (n=459) TA (n=571)
30 day 93.7% 89.7%
EuroSCORE <20 94.6%(Mean 12.5)
93.4%(Mean 12.4)
EuroSCORE >20 93.3%(Mean 33.7)
63% of pts
88.1%(Mean 36.3)
70% of pts
Survival
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Fraction of Months post Procedure
Su
rviv
al
< 20 >= 20
SOURCE 30 Day All Cause Mortality -- Transfemoral ApproachStratified by Logistic EuroSCORE
SOURCE 30 Day All Cause Mortality -- Transapical ApproachStratified by Logistic EuroSCORE
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Fraction of Months post Procedure
Su
rviv
al
< 20 >= 20
p=0.068
Survival of TA pts with ES< and >20 are significantly different (93.4 vs. 88.1) (p=0.067)
Patients entering the VALVETEAM screening process (n=181)Patients entering the VALVETEAM screening process (n=181)
TAVI vs Surgical AVR
Challenging clinical scenariosChallenging clinical scenariosBicuspid valves
CAD + AS
Non severe AS in pts undergoing CABG
Renal failure patients
Dye allergy
Health economics
Current surgical candidatesCurrent surgical candidatesMinimization of invasiveness To mitigate risks Increase acceptance
Tailored treatment Anatomical substrate Underlying disease Patient needs
•Perioperative care•Pain management•Best prosthetic material
•Perioperative care•Pain management•Best prosthetic material
Surgical Approaches: Conventional and Minimally
Invasive Cardiac Surgery
Surgical Approaches: Conventional and Minimally
Invasive Cardiac Surgery
Conventional Minimally Invasive
Minimally invasive surgeryMinimally invasive surgeryMini-incisions
Abolition of CPB
Conventional and Minimally Invasive IncisionsConventional and Minimally Invasive Incisions
Mitral Valve SurgeryAortic Valve Surgery
Soft Tissue Retractor Placement –Used For Exposures in Minimally Invasive Cardiac SurgerySoft Tissue Retractor Placement –Used For Exposures in Minimally Invasive Cardiac Surgery
Level 3: RoboticsLevel 3: RoboticsFemoral Arterial & Venous Cannulation
Optional Direct Cannulation With Straight Shot Cannula
IJ Coronary Sinus Catheter
IJ Pulmonary Vent
EndoClamp Occlusion Balloon
Only Mitral Valve Replacements, Mitral Valve Repairs, ASDs & CABG Can Be Done At This Time
Trans-incision Visualization –The Aortic ValveTrans-incision Visualization –The Aortic Valve
AVR – CHOICE OF THE PROTHESISAVR – CHOICE OF THE PROTHESIS
Barnett et al JTCVS 2009
The revalving conceptThe revalving concept
Expanding durabiltyExpanding durabilty
Is valve device industry investing in surgical AVR?Is valve device industry investing in surgical AVR?
Minimally invasive approaches
Sutureless valve
No anticoagulation
More durable tissue valves
Exchangeable valves
Valve-X-change: the lifetime valveValve-X-change: the lifetime valve
Zlotnick et al Circulation 2008
Apicoaortic conduitsApicoaortic conduits
Edwards SAPIENEdwards SAPIEN™™ THV THV Edwards SAPIENEdwards SAPIEN™™ THV THV
Subclavian access (Corevalve TM)Subclavian access (Corevalve TM)Subclavian access (Corevalve TM)Subclavian access (Corevalve TM)
Short delivery distanceShort delivery distance
PainlessPainless
Local anesthesiaLocal anesthesia
Retrograde approachRetrograde approach
conclusionsconclusionsAortic stenosis can be treated with low risk in different ways
Percutaneous and transcatheter modalities are emerging
Guidelines will be revised
Open mind and collaborative efforts are key
Clinical wisdom is today the only tool available to guide the decision