TAVI for Aortic Stenosis

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TAVI for Aortic Stenosis

• Mark Webster
• Interventional Cardiologist
• Auckland City Hospital

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Aortic Valve Disease
Normal Stenosed
Causes Degenerative Congenital mainly
bicuspid valve Rheumatic Others - less common
(including supra-aortic, subaortic)
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• Natural History of Aortic Stenosis

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Severe Symptomatic Aortic StenosisNatural
History Surgical Aortic Valve Replacement
Lethal condition No randomised trials of surgical
AVR Convincing registry data
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Asymptomatic Aortic Stenosis
Circulation. 2010121151-156
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Surgical Aortic Valve Replacement
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Surgical Aortic Valve Replacement

• Excellent operation
• Mechanical valve
• permanent anticoagulation with warfarin
• Bioprosthetic valve
• valve degeneration over time
• TAVI valve-in-valve an option

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Medtronic CoreValve Self-expanding Nitinol
Frame with Porcine Pericardial Leaflets
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Edwards Sapien Balloon-Deployed Aortic Valve
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BSC Sadra Lotus
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Edwards Transfemoral Delivery System
Balloon Valvuloplasty
Aortic Arch Navigation
Native valve crossing
Final assesment
Edwards SAPIEN THV deployment
Procedure steps
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Trans-Aortic Gradient
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PARTNER Study Design
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PARTNER Inoperable Patients
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PARTNER High-risk AVR Patients
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TAVI Real World Experience
French TAVI registry 3195 patients 2010-2011 Age
mean 83 years, MF 11 NYHA III/IV 76 Logistic
Euroscore mean 22 Edwards Sapien 2/3, Corevalve
1/3 Transfemoral 75, transapical 18 Procedural
success 97 Death 10 at 30 days, 24 at 1
year Stroke 4 at 1 year
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Vascular Access

• Peripheral vessels satisfactory
• 7-8mm diameter, tortuosity, calcification
• Transfemoral
• 60-90, influenced by device calibre
• Peripheral vascular disease
• Transapical
• Subclavian
• Transaortic

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Procedural Complications

• Death
• Myocardial infarction coronary occlusion
• Stroke - 3-4
• Vascular injury
• 24F 18F 14F (1F 3mm)
• Pacemaker
• 30 CoreValve, 5-6 Edwards
• Para-valvar aortic regurgitation
• mild common, associated worse outcome

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TAVI Current Auckland Status

• Auckland City Hospital
• High-risk patients who are surgical candidates
• Multidisciplinary group meeting decides surgical
  AVR or TAVI
• Inoperable patients are ineligible for TAVI
• Mercy
• Mostly self-funded

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Summary

• Severe aortic stenosis is a lethal condition
• Medical treatment , balloon valvuloplasty may
  improve symptoms but not prognosis
• Surgical AVR remains the gold standard
  intervention
• Many with severe aortic stenosis are elderly,
  with multiple co-morbidities increasing risk of
  surgery
• TAVI is an excellent, less invasive alternative
  with equivalent outcomes to 2 years in high-risk
  patients

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Suitable Patient for TAVI

• Severe, symptomatic aortic stenosis
• exertional SOB, angina, syncope/ pre-syncope
• Symptoms due to aortic stenosis
• beware concomitant COPD
• balloon valvuloplasty may have diagnostic role
• Co-morbidities increasing surgical risk vascular
  disease, previous stroke, lung disease, renal
  dysfunction, previous CABG, porcelain aorta
• Very elderly recovery time
• Expectation of good quality of life
  post-procedure
• Good clinical judgement !