AORTIC STENOSIS IN ELDERLY IN 2019

HOW TO DECIDE FOR SURGERY OR TAVR?

WHEN TO INTERVENE?WHICH INTERVENTION?

Pr Jean-Luc Vandenbossche

CHU St-Pierre ULB

CHARACTERISTICS OF AORTICSTENOSIS IN ELDERLY

• Increasing incidence

• Progressive disease

• Physiopathology: atheromatosis and inflammation

• Under-estimation of symptoms

• Unfavorable prognostic without intervention

• Increased operative risk

• Polymorphic hemodynamic presentation

• Possibility of prevention?

Prevalence of aortic stenosis according

to age

Natural history of aortic stenosis

CLINICAL NATURAL HISTORY OF AORTIC STENOSIS

WHAT MEANS “SEVERE” AORTIC STENOSIS?

• Stage where symptoms and signs of hemodynamic

intolerance do appear; empirically, it has been

observed that these occurs when

• -surf<1cm2, and/or

• -mean grdt >40mmHg and/or

• -Vmax>4m/s

• Beneath, rarely occurrence of symptoms.

CONCORDANT

DISCORDANT

ALGORITHM TO ASSESS SEVERITY

ALGORITHM TO MANAGE SEVERE STENOSIS

EVALUATION OF SURGICAL RISK

CHOICE OF INTERVENTION IN SYMPTOMATIC AS

PRATICABILITY OF THE FEMORALACCESS

•Partner 1A 2011: 70%

•Partner 2 2016: 76%

•Sapien 3 2017: 88%

•SurTavi 2017: 94%

•Evolute pro 2018: 99%

Valve

Technology

SAPIEN SAPIEN XT SAPIEN 3

Sheath

Compatibility

Available

Valve Sizes

23 mm 26 mm 20 mm 23 mm 26 mm 29 mm

SAPIEN PLATFORMS IN PARTNERDEVICE EVOLUTION

22-24F 16-20F 14-16F

23 mm 26 mm 29 mm

7-8mm(2000-2010) 6-7mm(2010-2015)5-6mm(>2015)

Angio CT: abdominal aorta and iliac arteries: severe atherosclerotic

tortuosities and calcifications

Voie fémorale non –praticable

Refuse la chirurgie

Refuse le TAVI trans apical…

2014

Ins cardiaque…

Fémorales

imperméables

LIMA sur IVA

Angio NMR of cerebral arteries showing patency of Willis polygone

RESULTS AT 1 MONTH-17PTS (SERIES 2018)CAROTID ACCESS

CHU SAINT-PIERRE BRUSSELS

Mortalité: 12%

AVC: 12%

Troubles cognitifs sévères 8%

Pacemaker: 35%

IAO Paravalvulaire sévère 8%

Insuffisance cardiaque: 15%

Infarctus: 0%

Complications vasculaires: 0%

Hémorrhagies majeures: 0%

Insuffisance rénale: 8%

20 avril 2014

TAVI février 2014

13 janv 2015

Mars 2014

Juin 2017

March 2018!

Aortic debris and plaques associated with Porcelain Aorta

TIME TO EVENT CURVES FOR COMPOSITE END POINT AND INDIVIDUAL COMPONENTS ( PARTNER 3 2019)

SUBGROUP ANALYSIS FOR PRIMARY END POINT

PRIMARY END POINT

NON ISOLATED AORTIC STENOSIS

•CAD: 30-40% (eurosurvey)

•Ascending Aorta Dilatation : 20 %

•Mitral Regurgitation (mod-severe) : 20% (Partner)

•Carotid stenosis : 20-30 %

ASSOCIATED VALVULOPATHIES