tavr or savr: beyond the sts score · boston scientific abbot vascular 2. 5/24/2017 2 patient...
TRANSCRIPT
5/24/2017
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Juan Crestanello, MDDivision of Cardiac Surgery
TAVR or SAVR: Beyond the STS Score
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Lakshmi Prasad Dasi, PhDDepartment of Biomedical Engineering
The Ohio State UniversityWexner Medical Center
Disclosures
Dr. Dasi
▪ NIH/NHLBI
▪ NIH/NIBIB
▪ NIH/NCAI
▪ AHA
Dr. Crestanello Research Grants from: Medtronic Boston Scientific Abbot Vascular
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Patient Selection for SAVR vs TAVR
ExtremeInnoperable
Risk
High Risk
TAVR
Intermediate Risk
LowRisk
SAVR
Risk ProfileSTS PROM + Frailty + Other Comorbidities
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
Bicuspid Aortic Valve
LVOT Calcification
Small root-low lying coronary ostia
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Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
Bicuspid Aortic Valve
LVOT Calcification
Small root-low lying coronary ostia
Age and Life Expectancy: Longer Survival
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32
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8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
Survival General Population
Survival after Surgical AVR
Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 2000
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Surgical Valve Durability
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Freedom from Structural Valve Deterioration: Surgical AVR
Bourguinion et al. Ann Thorac Surg 2015
10-15 years
Age and Life Expectancy: Longer Survival
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32
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8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
Survival General Population
Survival after Surgical AVR
Freedom From SVD: Surgical AVR
Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 2000
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Age and Life Expectancy: Longer Survival
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32
24
17
8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80S
urvi
val (
Yea
rs)
Age
Survival General Population
Survival after Surgical AVR
32% 21% 12% 3%
REOPERATION
Freedom From SVD: Surgical AVR
Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 2000
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TAVR Durability
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TAVR Durability
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Age and Life Expectancy: Longer Survival
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32
24
17
8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
Survival General Population
Survival after Surgical AVR
Freedom From SVD: TAVR
HIGHER REOPERATION
RATE
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Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Ascending aortic aneurysms
Other
Valve and Aortic Root Anatomy
LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Ascending aortic aneurysms
Other
Valve and Aortic Root Anatomy
Annular and LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
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Annular and LVOT Calcification
Valve UnderexpansionParavalvular LeakAnnular Rupture
LVOT Calcification
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Annular and LVOT Calcification
Paravalvular Leak- opposing side
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Annular and LVOT Calcification
Aortic View Annular View
Finite element modeling
Crimping stores energy into the nitinol valve frame
Valve frame does work to push calcified leaflets open
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Annular and LVOT Calcification
Stent conformation over calcification results in flow paths
Potential for predictive modeling to optimize
Placement
Device selection
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Annular and LVOT Calcification
Computational Fluid DynamicsSimulation
Potential to couple fluids simulations with finite element modeling for pre-operative planning
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
Annular and LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
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Small Root – Low Lying Coronary Ostia
1-3% of population
More common in women
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Small Root – Low Lying Coronary Ostia
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The flow area for coronary bound flow can be complex due to:
Height, calcification, and width
Simulations and/or geometrically aligned indices better predict than just height
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Small Root – Low Lying Coronary Ostia
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Device specific variation in leaflet position
Possible room for device selection and coronary protection for inoperable patients
Cylinder PorticoCoreValve
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
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Bicuspid Aortic Valve
2-3% of population
More common in the young
20% elderly patients with AS
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Bicuspid Aortic Valve
Asymmetric cusps
More calcified
Asymmetric calcification
More circular annulus
Larger
Sinuses of Valsalva
STJ
Ascending aorta
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Philip et al Catheterization and Cardiovascular Interventions 2015
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Bicuspid Aortic Valve
Device under-expansion
Higher rate of
Paravalvular leak
Second device
Annular rupture
Conversion to surgery
Improved with newer devices
Simulations?
Fate of the ascending aorta?
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Yoon et al JACC 2015
Summary – So what is beyond STS score?
Clinical outcomes
Durability
Concomitant diseases
Mitral, Coronary, Other
Valve and Aortic Root Factors LVOT Calcification Low Lying Ostia Bicuspid
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Directly impacts hemodynamics and
valve durability
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Acknowledgement
WMC Structural Heart Group – esp. Jennifer Dollery
Doctoral Students: Amir Azimian, Hoda Hatoum, Atieh Yousefi
Funding: NIH, DHLRI-Trifit
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