TAVI „Catch me if you can!“

Eberhard Grube, MD Honoraria: Boston Scientific Corporation Biosensors International Consulting Fees: Medtronic CoreValve Cordis Corporation Johnson & Johnson Abbott Vascular

Eberhard Grube, MD Ownership Interest (Stocks, Stock Options, or other Ownership Interest): Medtronic Core Valve Biosensors International My presentation will include off-label discussions: Off-label use of Stents and Valve Prosthesis

Patient characteristics Patient Demographics Past Surgical History Age: 79 years Gender: male Pacemaker implantation (2006) PCI LMS/RCX (2006) PCI D1 (Oct 2011) Past Medical History Non-Hodgkin lymphoma (2001) Ischemic stroke (2005) Coronary artery disease Chronic renal failure (eGFR 35 mL/min) Atrial fibrillation COPD Pulmonary hypertension (sPAP 60 mmHg) Upper GI-bleeding (Oct 2011) Clinical Presentation Dyspnea NYHA IV Acute cardiac decompensation with pleural effusions

Screening Imaging Studies Procedural Strategy Clinical Indication Heart catheterization: 2-vessel-CAD with patent stents in LMS, RCX and D1 CT scan: Aortic annulus 27.9 x 23.5 mm2, perimeter 81 mm Sufficient diameter of aortoiliac vessels for transfemoral access Echo: Severe aortic stenosis, AVA 0.9 cm2, annulus 28 mm, AR 2, MR 1 Procedural Strategy Transfemoral TAVI (31mm prosthesis) with cerebral protection device Clinical Indication Severe aortic stenosis with comorbidities High surgical risk (STS score 9.3%, log. EuroSCORE 37.4%)

Aortic annulus Max. diameter: 27.9mm Min. diameter: 23.5mm Perimeter: 81 mm

Aortic regurgitation Index = [(RRdia – LVEDP) / RRsys] x 100 RRsys 110 mmHg RRdia 37 mmHg LVEDP 7 mmHg Aortic regurgitation Index = [(RRdia – LVEDP) / RRsys] x 100 = [(35 - 7) / 110] x 100 = 25.5

11.74mm 10.83mm

Clinical course post-TAVI Patient stable without need for catecholamines after the procedure Development of acute kidney injury on day 2 Acute cardiorenal syndrome with pleural effusions and dyspnea NYHA IV

Aortic regurgitation Index = [(RRdia – LVEDP) / RRsys] x 100 RRsys 120 mmHg RRdia 40 mmHg LVEDP 20 mmHg Aortic regurgitation Index = [(RRdia – LVEDP) / RRsys] x 100 = [(40 – 20) / 120] x 100 = 16.7

13.20mm +1.5mm 12.33mm +1.5mm

4.18mm -9.0mm 3.16mm -9.2mm

Aortic regurgitation Index = [(RRdia – LVEDP) / RRsys] x 100 RRsys 150 mmHg RRdia 60 mmHg LVEDP 15 mmHg Aortic regurgitation Index = [(RRdia – LVEDP) / RRsys] x 100 = [(60 - 15) / 150] x 100 = 30.0

Moderate/Severe periprosthetic AR Blue: Medtronic CoreValve Green: Edwards-SAPIEN

Periprosthetic Aortic Regurgitation Sinning, Grube, et al., JACC in press

Impact of peri-AR on 1-year survival Sinning, Grube, et al., JACC in press

Hemodynamics of mild peri AR Sinning, Grube, et al., JACC in press

Moderate/Severe peri AR Sinning, Grube, et al., JACC in press

AR index and severity of periAR Sinning, Grube, et al., JACC in press

Impact of AR Index on 1-year survival Sinning, Grube, et al., JACC in press

Thank you very much