Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indications
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By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
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Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indications
- 1. Transcatheter AVRTranscatheter AVR Established and EmergingEstablished and Emerging IndicationsIndications Paul Sorajja, MD Director, Center for Valve and Structural Heart Disease Minneapolis Heart Institute Abbott Northwestern Hospital Disclosures: proctoring, consulting with Abbott Vascular
- 2. 83 year-old man83 year-old man What would you do next?What would you do next? Heart failureHeart failure Prior CVAPrior CVA Hx CABGHx CABG
- 3. Patients in needPatients in need 1/3 had symptomatic AS but no1/3 had symptomatic AS but no operationoperation Bach DS et al., Circ CV Qual Out 2009Bach DS et al., Circ CV Qual Out 2009 Michigan surveyMichigan survey 369 patients369 patients
- 4. Age (years) Osnabrugge RL, et al. JACC 2013;13:2079-2Osnabrugge RL, et al. JACC 2013;13:2079-2 Nkomo et al. Lancet, 2006;368:1005-11Nkomo et al. Lancet, 2006;368:1005-11 Prevalence ~3.4%Prevalence ~3.4% 75% symptomatic75% symptomatic 102,558 high-risk or102,558 high-risk or inoperableinoperable 9,189 added annually9,189 added annually AllAll MitralMitral AorticAortic Burden of Aortic StenosisBurden of Aortic Stenosis U.S. and CanadaU.S. and Canada
- 7. Inoperable PatientsInoperable Patients p<0.0001p<0.0001 Standard RxStandard Rx TAVRTAVR All-cause mortality (%)All-cause mortality (%) MonthsMonths 00 2020 4040 6060 8080 100100 NNT to save one life: 5NNT to save one life: 5 50.750.7 30.730.7 Leon et al., NEJM 2010Leon et al., NEJM 2010
- 8. High Surgical RiskHigh Surgical Risk 0 10 20 30 40 50 60 0 6 12 18 24 30 36 DeathfromAnyCause(%) Months Hazard ratio, 0.90 (95% CI, 0.71-1.15) P=0.41 Surgery TAVR Adams D, et al. N Engl J Med 2014Adams D, et al. N Engl J Med 2014 Kodali S, et al. N Engl J Med 2011Kodali S, et al. N Engl J Med 2011
- 9. Available TAVRAvailable TAVR LabelingLabeling • Symptomatic severe ASSymptomatic severe AS • Inoperable (I) or High-risk (IIa)Inoperable (I) or High-risk (IIa) • 18 to 29 mm (but use CT area)18 to 29 mm (but use CT area) ResearchResearch • Intermediate risk (3 to 8%)Intermediate risk (3 to 8%) • New valves and new approachesNew valves and new approaches
- 11. The New GenerationThe New Generation Active lifestyleActive lifestyle Like less invasiveLike less invasive InnovativeInnovative
- 14. - Walter Lillehei- Walter Lillehei What mankind canWhat mankind can dream, research anddream, research and technology cantechnology can achieveachieve
- 15. Abbott Northwestern HospitalAbbott Northwestern Hospital MHI Center for Valve and SHDMHI Center for Valve and SHD November 12, 2013: First mitral valve-in-valve therapy using an Edwards Sapien prosthesis in the U.S. December 11, 2013: First worldwide treatment of obstructive hypertrophic cardiomyopathy with the MitraClip device January 25, 2014: First commercial implant of a Medtronic CoreValve in the U.S. July 1, 2014: Establishment of a SHD interventional fellowship August 13, 2014: First successful therapy with MitraClip in the U.S. performed independently of industry clinical support September 23, 2014: 250th case of transcatheter aortic valve implantation performed at Abbott Northwestern Hospital
- 16. Key pointKey point Think of transcatheterThink of transcatheter valve therapy for any highvalve therapy for any high risk patientrisk patient
Notes de l'éditeur
- Flail mitral eclip in 88 yo
- In the US, there also is a large number of pts with severe sx AS who are not undergoing open surgery This was a survey of In this report, like the EuroHeart survey, 1/3 Cited morbidity, pt refusal; few pts actually saw surgeon IS THERE DATA ON IMPROVED ACCESS ONCE TAVR BECAME AVAILABLE IN EU?
- Focus of this slide is on REGURGITANT DISEASE... Mitral regurgitation is the most common type of heart valve insufficiency in the US Prevalence increases with increasing age, from 0.5% for 18-44 yr olds rising to 9.3% for ≥75 year olds (p&lt;.0001)
- Add 30 day mortality and long-term survival
- Valve in valve mitral
- And the trend for latest and greatest in medicine is to go smaller and less invasive
- So they appreciate it when we can be innovative and do things with less intrusion