What Do Low Risk Aortic Stenosis Patients Want? Paul D. Mahoney, - - PowerPoint PPT Presentation

What Do Low Risk Aortic Stenosis Patients Want?

Paul D. Mahoney, MD, FACC Director Sentara Structural Heart and Complex Interventional Programs

Disclosures

 Consultant and Physician Proctor

 Medtronic  Edwards Lifesciences  Boston Scientific

 Research Support

 Medtronic (SURTAVI Trial)  Edwards (PARTNER, Early TAVR)

Greetings from Norfolk, Virginia

What Do Low Risk TAVR Patients Really Want?

They want to Move Like Jagger… Patients being considered for TAVR vs SAVR have changed dramatically… 75 year olds can be very active

New Concept in TAVR: Patient Centered Discussion

• Patient input not part of medical decision

making in original TAVR NCD

• Patient specific, not procedure specific,

case planning

• What Patients want (and physicians need

to provide): Informed consent on individual risks and benefits, and involvement in medical decision making

What do low risk AS patients want?

• Primary Focus: Fix the Problem

 Fix the valve effectively  Lowest risk of death/complication  Least disruption of normal life

• Critical Secondary Discussions

 Durability  Functional Status  Freedom from device associated complications

• Pacemakers
• Cor access
• Valve in Valve suitability

What do low risk patients want: “Fix the Problem” -- TAVR vs SAVR

Evolut Low Risk Partner 3

Endpoint: Death, Stroke, Rehospitalization

“TAVR Suitability in Low Risk”: We need to change the conversation….

• Concept of “Surgical Risk” is outdated

 This construct of only looking at surgical risk no longer

serves our patient population

 Instead of considering surgical risk; Consider TAVR

suitability

• When is SAVR more suitable than TAVR?
• What patient specific factors lead to favoring surgery or

catheter based valve replacement in low risk patients?

 optimal treatment strategies individualized to patients

Lets Look at two “low Surgical Risk” AS Patients

• Patient B --- STS 2.0%
• 59 years old
• Diabetic (insulin), Creat of 2.0
• Bicuspid, calcified raphe
• Low Coronary Heights
• Ascending aortic aneurysm
• Patient A --- STS 2.0%
• 84 years old
• No prior surgery, otherwise healthy
• Primary caretaker for husband with

dementia

we should seek optimal, individual approaches for any risk patient when considering SAVR vs TAVR!

TAVR for Any Risk Patients

Who Does Well with TAVR?

Calcific trileaflet aortic stenosis

avoid some bicuspid aortic valves

Acceptable aortic valvar complex

annulus size well matched to valve size availability, avoid surgical Patient Prosthesis Mismatch, calcium patterns, ascending aortic pathology

Percutaneous femoral access

– strongly preferred

• subclavian equivalent?

Absence of unfavorable anatomies –

“surgical” CAD, multi-valve disease

• Kodali, TCT 2017

Targeting SAVR in lower risk patients: What makes TAVR less favorable?

• Hostile aortic root complex

 low cor height, narrow sinuses, root

enlargement, Calcium pattern, large annulus

• Lack of TF Access
• Concomitant surgical CAD
• Patient age / Durability

???

Low Coronary Height – Risk of Coronary Occlusion

Surgery favored in situations where increased risk of catastrophic complications in a lower risk patient

Hostile calcification patterns

Higher risk of annular rupture with severe LVOT calcification Should be considered in SAVR vs TAVR Annular rupture

Acc.org

SAVR for large annuli or unfavorable Calcification: More than Mild PVL carries survival disadvantage

N Engl J Med 2016; 374:1609-1620

Anatomy with higher risk for PVL should favor surgical approach in low risk patients

Annular area 817 mm2 Perimeter 102 mm

Should patient AGE and valve DURABILITY be significant considerations in low risk patients?

• Need more data on THV durability out to 10-

12 years

Average age of surgical valve undergoing valve in valve: 8 - 9 years

Partner 5 year data – no reintervention

Mack M et al. Lancet 2015;6736(15)60308-7

What Do Low Risk Patients Want: Optimal Hemodynamics

• Avoid PPM with SAVR… or TAVR

STS Data Fallon et al TVT Data Herrmann et al

Increased Mortality: Severe PPM vs no/Mod

Severe PPM

What do low risk patients want? Freedom from TAVR Associated Long Term Issues

• RV Pacing not entirely benign

 Mortality signal after 5 years RV pacing

• Access to coronaries post implant
• Suitability for TAV in TAV

 Cor occlusion, Sinus sequestration

• Novel Techniques developing in parallel

What Does the Low Risk AS Patient Want: TAVR vs TAVR

• What is the IDEAL TAVR prosthesis?

 Lowest Procedural Risk (anatomy)  Most Durable  Best HDs  Lowest pacer rate  Least interference with cor access  Most suitable for TAV in TAV in future

2

Thank you!

@PaulMahoneyMD