1. Decision Making In Aortic Stenosis From Surgical AVR with Sutured or Sutureless Valves to TAVI
Niv Ad, MD
Chief, Cardiac Surgery
Professor of Surgery, VCU
Inova Heart and Vascular Institute

2. Disclosures Niv Ad: Medtronic Inc. - Consultant
Atricure Inc.- Consultant
Sorin - Consultant
Left Atrial Appendage Occlusion LLC – Co Owner

3. A Few Observations

4. The Heart Valve Team

5. Who is going to have it?

6. Who is going to have it?

9. The Importance PVL

10. The SJD Portico Trial
Reduced leaf mobility?

11. What Are the Key Questions Associated with Patients Selection ?
Can we base our policies on a few industry sponsored studies ? (even if prospective randomized)
What is the weight of biological (comorbidities) and anatomical variables ?
How important are?
Lower diameter and aggressive crimping
Newer valve designs not requiring a cage
Native valve

12. What Are the Key Questions Associated with Patients Selection ?
Can we base our policies on a few industry sponsored studies ? (even prospective randomized)
What is the weight of biological (comorbidities) and anatomical variables ?
How important are?
Lower diameter and aggressive crimping
Newer valve designs not requiring a cage
Native valve

14. What Are the Key Questions Associated with Patients Selection ?
Can we base our policies on a few industry sponsored studies ? (even prospective randomized)
What is the weight of biological (comorbidities) and anatomical variables ?
How important are?
Lower diameter and aggressive crimping
Newer valve designs not requiring a cage
Native valve

17. JTCVS 2014

20. Over 80 years Old Perioperative Outcomes (STS <3%)
AVR/CABG
N=47
Isolated AVR
N=41
Deep Sternal Wound Infection
Perioperative MI
Septicemia
1 (2%)
Prolonged Ventilation (24 h)
2 (4%)
2 (5%)
Pneumonia
Permanent Stroke
TIA
Reoperation for Bleeding GI
Renal Failure
Renal Failure Requiring Dialysis
Operative Mortality
Readmission <30 Days
4 (8.5%)
3 (7%)

21. Two-Year Survival (STS <3%)
AVR/CABG
N = 47
Isolated AVR
N = 41

22. Two-Year Survival (STS <5%)
AVR/CABG
N = 144
Isolated AVR
N = 89

23. Perceval S – Bovine Percardium and Nitinol stent

29. Freedom from Re-Operation

42. What Are the Key Questions Associated with Patients Selection ?
Can we base our policies on a few industry sponsored studies ? (even prospective randomized)
What is the weight of biological (comorbidities) and anatomical variables ?
How important are?
Lower diameter and aggressive crimping
Newer valve designs not requiring a cage
Native valve

44. What Are the Key Questions Associated with Patients Selection ?
Can we base our policies on a few industry sponsored studies ? (even prospective randomized)
What is the weight of biological (comorbidities) and anatomical variables ?
How important are ?
Lower diameter and aggressive crimping
Newer valve designs not requiring a cage
Native valve

45. The Impact of TAVR on Patients Selection for SAVR

46. The Impact of TAVR on Patients Selection for SAVR
8.8%
2.2%
2.3%

47. Summary
With the availability of a novel treatment option for aortic stenosis in high-risk patients, institutions offering these alternative methods will be forced to reevaluate patient management.
A careful strategy that includes multidisciplinary evaluation is crucial in order to have a successful transcatheter aortic valve program.

48. Conclusions Sutureless Aortic valve is significant in:
Reducing operating time
Minimally invasive procedure
Ease of implant (control variability)
Long term outcomes are unknown
PVL
Durbility

49. The Heart Valve Team

50. But

51. Conclusions
Low risk patients including older patients should have SAVR regardless the number of sutures
Special considerations:
Anatomy (Calcium and Bicuspid)
Frailty
Renal Failure
CAD
Redo procedures

52. THANK YOU