Post on 20-Aug-2020
TAVI, TMVI, TEVAR, EVAR: The end of standard Cardiovascular Surgery? Perspectives of a Cardiac Surgeon
Daniel Fink MDDept. of Cardiothoracic SurgeryShaare Zedek Medical Center
Jerusalem, Israel
Disclosures
Just a plain Cardiothoracic Surgeon
KISS Principle( keep it simple s…..)
I have no conflicts of interest
Historical Background
Traditional Aortic Valve Replacement and Open Thoracoabdominal Aneurym Repair are well established and long standing therapies.
Both procedures have excellent long term effects with acceptable risk factors.Operative risk is affected by both age and comorbidies( EUROSCORE, STS score).
With increase in aged and sicker population CONVENTIONAL SURGERY is being avoided!!!
WHAT DO WE DO???
Development of lesser invasive therapies!!
Catheter based Valve implantation
Endovascular Stent Implantation
Transcatheter Valve
Endovascular Stent Grafting
TEVAR
Benefits of TAVI
Excellent Hemodynamic- low transvalvulargradients!!!!
Percutaneous
Multiple Applications- “ Valve in Valve”; Calcified MV – native??; Trans Apical & Aortic
Drawbacks
Paravalvular Leak
Pacemaker Requirement
Non suitability in BAV
COST!!!!!!!!!!
DURABILITY??????
Two-Year Outcomes in Patients With Severe Aortic
Valve Stenosis Randomized to Transcatheter Versus
Surgical Aortic Valve Replacement
by Lars Søndergaard, Daniel Andreas Steinbrüchel, Nikolaj Ihlemann, Henrik
Nissen, Bo Juel Kjeldsen, Petur Petursson, Anh Thuc Ngo, Niels Thue
Olsen, Yanping Chang, Olaf Walter Franzen, Thomas Engstrøm, Peter
Clemmensen, Peter Skov Olsen, and Hans Gustav Hørsted Thyregod
Circ Cardiovasc Interv
Volume 9(6):e003665
June 13, 2016
Copyright © American Heart Association, Inc. All rights reserved.
Kaplan–Meier curves depicting (A) a composite rate of all-cause mortality, all stroke,
and myocardial infarction (MI); (B) all-cause mortality; (C) composite rate of all-cause
mortality, all stroke, and MI in transcatheter aortic valve replacement (TAVR) and
surgical aortic valve replacement (SAVR) patients with Society of Thoracic Surgeons
Predicted Risk of Mortality (STS-PROM) <4%; and (D) composite rate of all-cause
mortality, stroke, and MI in TAVR and SAVR patients with STS-PROM ≥4%.
Lars Søndergaard et al. Circ Cardiovasc Interv.
2016;9:e003665
Copyright © American Heart Association, Inc. All rights reserved.
Date of download: 9/7/2016 Copyright © The American College of Cardiology. All rights reserved.
From: Transcatheter Aortic Valve Replacement in Europe: Adoption Trends and
Factors Influencing Device Utilization
J Am Coll Cardiol. 2013;62(3):210-219. doi:10.1016/j.jacc.2013.03.074
TAVR Adoption in Europe
(A) Cumulative transcatheter aortic value replacement (TAVR) implants in 11 Western European
nations between 2007 and 2011. (B) TAVR implants per annum and percentage annual increase
(solid line).
Figure Legend:
Date of download: 9/7/2016 Copyright © The American College of Cardiology. All rights reserved.
From: Transcatheter Aortic Valve Replacement in Europe: Adoption Trends and
Factors Influencing Device Utilization
J Am Coll Cardiol. 2013;62(3):210-219. doi:10.1016/j.jacc.2013.03.074
TAVR Implants per Million Population in the Study Nations
TAVR implant dynamics in the study nations between 2007 and 2011. (A) TAVR implants per million
population. (B) TAVR implants per million population age ≥75 years. Broken line represents mean.
Abbreviation as in Figure 1.
Figure Legend:
TAVI vs. sAVR in Israel 2015
0
200
400
600
800
1000
2015
Cas
es
surgical AVR
TAVI
Cost per case:sAVR 15,480 €TAVI 48,000 €
Number of procedures
0
10
20
30
40
50
60
70
80
2011 2012 2013 2014 2015
surgical AVR TAVI
(%) Operative Mortality
0
5
10
15
20
25
2011 2012 2013 2014 2015
surgical AVR
TAVI
Is this the end of sAVR?
Figure 2. University of Alabama at Birmingham isolated aortic valve replacement volume from 2009 through 2014. SAVR, surgical
aortic valve replacement; TAVR, transcatheter aortic valve replacement.
James E. Davies Jr., William W. McAlexander, Mark F. Sasse, Massoud A. Leesar, Spencer J. Melby, Satinder P. Singh, Lindsey
B. Jernigan, Oscar J. Booker, Oluseun O. Alli
Impact of Transcatheter Aortic Valve Replacement on Surgical Volumes and Outcomes in a Tertiary Academic Cardiac
Surgical Practice
Journal of the American College of Surgeons, Volume 222, Issue 4, 2016, 645–655
http://dx.doi.org/10.1016/j.jamcollsurg.2015.12.054
sAVR in Transcatheter Era
Sutureless Tissue Valves
Benefits of Sutureless Valves
Excellent Hemodynamics
Easy Deployment
Minimally Invasive Technique
Short CPB
Durability?
Costs- lower than TAVI
BEST OF ALL WORLDS
Minimally Invasive Aortic Valve Replacement( MIAVR)
ENDOVASCULAR REPAIR- Advantages
Minimally Invasive
Less Morbidity & Complications
LOS
Disadvantages
Suitabilty- Proper Landing Zones; CTD
Endoleaks
Migration & Graft Collapse
Durability ?
Fenestrated/Branched Thoracic Endovascular Aneurysm Repair
Author, Year
Number of Patients
Mortality
Paraplegia and Paraparesis
Renal Failure
Technical Success
Endoleak Re-Intervention
Roselli2007
73 5.5 2.7 1.4 93 18 29
Haulon2009
33 9 15 9 - 15 3
Verhoeven2009
30 6.7 16.7 3.2 93 - 6.7
Guillou2012
89 10 7.8 6.7 96.6 21 4.2
Kitagawa 2013
30 0 0 0 100 66.7 33.3
Oikonomou 2014
31 9.6 12.9 3.2 93.5 38.7 32.3
Open Repair of ThoracoabdominalAneurysms
Author, Year Number of Patients
Extent 1 and 2
Mortality Paraplegia and
Paraparesis
Renal Failure
Svennson1993
1,509 54.3 8.3 15.5 17.8
Safi 2003 1,004 41.6 14 3.6 NA
Coselli 2007 2,286 64.2 5 3.8 5.6
Acher 2008 637 37.9 2.7 5.5 2.6
Girardi 2015 675 48.5 5.6 2.8 5.2
Endovascular Repair-Recommendations
Acute Complicated Type B Aortic Dissection
Blunt Traumatic Aortic Injury
Penetrating Aortic Ulcers
Ruptured Descending Thoracic or TAA- high risk
Avoid
CTD
Mycotic Aneurysms
Infected Grafts
Aortic Fistulae
Ascending Aorta & Arch???? / Type A Dissections ?
HYBRID
Class Level
TAVIshouldonlybeundertakenwithamultidisciplinary“heartteam”including
cardiologistsandcardiacsurgeonsandotherspecialistsifnecessary.I C
TAVIshouldonlybeperformedinhospitalswithcardiacsurgeryon-site. I C
TAVIisindicatedinpatientswithseveresymptomaticASwhoarenotsuitablefor
AVRasassessedbya“heartteam”andwhoarelikelytogainimprovementintheir
qualityoflifeandtohavealifeexpectancyofmorethan1yearafterconsideration
oftheircomorbidities.
I B
TAVIshouldbeconsideredinhighriskpatientswithseveresymptomaticASwho
maystillbesuitableforsurgery,butinwhomTAVIisfavouredbya“heartteam”
basedontheindividualriskprofileandanatomicsuitability.
IIa B
www.escardio.org/guidelines
Indications fortranscatheter aortic valve implantation
doi:10.1093/ejcts/ezs455).
« In the absence of a perfect quantitative score, the risk assessment
should mostly rely on the clinical judgement of the ‘heart team’, in addition
to the combination of scores. »
European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 &European Journal of Cardio-Thoracic Surgery 2012 -
www.escardio.org/guidelines
High Surgical Risk?Decision between TAVI and AVR?
EuroScore ≥ 20%
STS score > 10%
Fraility
Chest radiation
Porcelain aorta
Re-operation
Conclusions
TVR, TEVAR, EVAR- established and effective therapies
Indications, Durability, Costs are evolving issues that need further studies.Designated Multidisciplinary Heart & Aortic Team are probably the most effective tool to develop the future applications of these technologies and establishing practice guidelines.RCT and “real life” registries are essential to determine long term resultsExtension of TVR to other Heart Valves is still unknown
CONCLUSIONS
Sutureless Valves and Minimally Invasive Surgery is a promising evolving option that may further extend the pool of patients for Surgical Valve Replacement
Hybrid approaches, Improved Stent Graft Technologies ( Branched Grafts) may be the future!!
SURGEONS MUST MASTER CATHETER BASED SKILLS!!!( “cath or perish”!!!)
THANK YOU!