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Transcatheter/Hybrid Aortic Valves in the Young

Published byJohnathan Reeves Modified over 9 years ago

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Presentation on theme: "Transcatheter/Hybrid Aortic Valves in the Young"— Presentation transcript:

1 Transcatheter/Hybrid Aortic Valves in the Young
Prof. Dr. Mirko Doss Kerckhoff Klinik, Bad Nauheim

2 AVR vs TAVR Implants

3 Indications for AVR in the Young
Congenital AV disease Rheumatic fever Intervention Endocarditis Repair Trauma Degenerative disorders AVR Significant valve destruction Failed repair Failed intervention Risk

4 Optimal substitute for AVR
Readily available in different sizes Excellent hemodynamic performance Growth potential Non-immunogenic Minimal thrombo-embolism Low structural valve degeneration incidence

5 Transcatheter procedures in the young
Melody Pulmonary Valve Bovine jugular vein Platinum Iridium frame

6 Available Sutureless Prostheses
Enable (Medtronic) Perceval (St Jude) Intuity (Edwards Lifesciences)

7 Available transcatheter prostheses
Device Status Features JENAVALVE (Jenavalve) CE - TA Devel. –TF - anatomical orientation - partial repositioning ENGAGER (Medtronic) MC trial -TA no TF ACURATE (Symetis) Clin.trial –TF partial repositioning intuitive positioning PORTICO (SJM) Clin.trial - TF Devel. - TA SAPIEN 3 (Edwards) Clin. Trial -TF+TA - PV leak prevention

8 Transcatheter vs Sutureless AVR

9 Access routes for the young
Transapical Transfemoral Transaortic  2 cm  5 – 5.5 cm

10 TA: get as minimally invasive as TF
Percutaneous TA access & closure: (1) small incisions non rib spreading approach (2) Validated access & closure devices (3) Truly percutaneous? => Imaging! CardiApex

11 Edwards Sapien example: SAPIEN 3

12 TA- ACURATE (2011) Symetis

13 TA- Engager Medtronic

14 TAVR Complications Paravalvuar leakage AV Block Migration
Leaflet dysfunction Annulus ruptur Dissection/ perforation Coronary obstruction Mitral valve dysfunction

15 TAVI Results

16 Cohorte B Mortality

17 Cohorte A Mortality

18 Echocardiographic Findings (AT)
TAVR AVR Valve Area (cm2) p = 0.001 p = 0.002 p = 0.003 p = 0.16 Core lab echocardiographic analysis reveals that mean valve area improves to ~1.5cm2 and there is no evidence of deterioration in either arm over two year follow-up. Numbers at Risk TAVR 301 269 223 210 139 AVR 290 224 162 151 110

19 Echocardiographic Findings Mean and Peak Gradients (AT)
Peak Gradient - TAVR Mean Gradient - TAVR Peak Gradient - AVR Mean Gradient - AVR Gradient (mmHg) Mean gradients are reduced to ~10 mmHg and they remain stable over the course of two year follow-up. Numbers at Risk TAVR 307 275 233 218 144 AVR 295 228 168 155 112

20 Paravalvular AR and Mortality TAVR Patients (AT)
None - Trace Mild - Moderate - Severe HR [95% CI] = 2.01 [1.38, 2.92] p (log rank) = 39.5% Mortality 29.5% 24.8% 14.5% We sought to look at the impact of paravalvular AR on mortality. This KM curve reveals mortality is significantly higher in patients with mild-moderate-severe AR with a hazard ratio of The KM estimates for mortality at one year were doubled and at two years the mortality with mild-mod-severe Paravalvular AR was 39.5% vs. 24.8% in those with none-trace paravalvular AR. Months Post Procedure Numbers at Risk None-Tr 167 149 140 126 87 41 16 Mild-Mod-Sev 160 134 112 101 64 26 12

21 Total AR and Mortality TAVR Patients (AT)
None - Trace Mild Moderate - Severe p (log rank) < 0.001 50.7% 35.3% 33.4% Mortality 26.2% 26.3% Separating these curves in three categories (none-tr vs. mild vs. mod-severe) shows an interesting stepwise increase in mortality with worsening AR. 12.7% Months Post Procedure Numbers at Risk None-Tr 135 125 115 101 68 31 11 Mild 165 139 121 111 71 33 16 Mod-Sev 34 25 22 19 15 6 2

22 German Aortic Valve RegistrY
One-year outcomes of transcatheter aortic valve implantation in consecutive patients C. W. Hamm, H. Möllmann, F.W. Mohr, A. Beckmann, F. Beyersdorf, J. Cremer, H.-R. Figulla, G. Heusch, D. Holzhey, K.-H. Kuck, R. Lange, T. Meinertz, T. Neumann, R. Zahn, K. Papoutsis, S. Sack, S. Schneider, G. Schuler, A. Welz, T. Walther for the GARY-Executive Board Christian W. Hamm Kerckhoff Heart and Thorax Center Bad Nauheim and Medical Clinic I, University of Giessen, Germany

23 TAVI Valve Type transvascular transapical n = 2.632 n =6.479 ™
Engager™ ™ ACURATE™ SAPIEN™ CoreValve™ SAPIEN™ n = 2.632 n =6.479

24 1-year follow-up: Stroke

25 GER 2011 Mandatory AQUA Quality assessment
AKL Score (Risikogruppen) Conv. AV Surgery expected observed T-AVI 0 - <3% 1,62 % 1,54 % 2,31 % 3,32 % 3 - <6% 4,03 % 3,18 % 4,35 % 5,44 % 6 - <10% 7,54 % 9,91 % 7,65 % 7,09 % ≥ 10% 20,22 % 18,7 % 17,99 % 13,94 % lower than expected mortality higher than expected mortality Courtesy of Prof. Welz

26 Large scale registry on surgical & TAVI procedures, all comers
Conclusions from GARY Large scale registry on surgical & TAVI procedures, all comers Excellent 1-year follow-up (98%) Continuous increase in mortality after hospital discharge, predominately in high risk groups. Surgical AVR better in low / intermediate risk TAVI and surgical AVR equal in highest risk groups

27 Conclusion In low risk consider suture less AVR
Less invasive procedures are the future In low risk consider suture less AVR In high risk consider TAVR TA: The FRONT DOOR approach

28 Thank you for your attention!

29 no personal financial disclosures

30 no personal financial disclosures

31 no personal financial disclosures

32 no personal financial disclosures

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