KERCKHOFF HERZ- UND THORAXZENTRUM Transcatheter/Hybrid Aortic Valves in the Young Prof. Dr. Mirko...

KERCKHOFF HERZ- UND THORAXZENTRUM

Transcatheter/Hybrid Aortic Valves in the Young

Prof. Dr. Mirko DossProf. Dr. Mirko Doss

Kerckhoff Klinik, Bad NauheimKerckhoff Klinik, Bad Nauheim


AVR vs TAVR Implants

0

1.000

2.000

3.000

4.000

5.000

6.000

7.000

8.000

9.000

10.000

94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

ohne kathetergeführte Eingriffe


Indications for AVR in the Young

• Congenital AV diseaseCongenital AV disease

• Rheumatic feverRheumatic fever InterventionIntervention

• EndocarditisEndocarditis Repair Repair

• TraumaTrauma

• Degenerative disordersDegenerative disorders AVR AVR

• Significant valve destructionSignificant valve destruction

• Failed repairFailed repair

• Failed interventionFailed interventionRisk


Optimal substitute for AVR

•Readily available in different sizesReadily available in different sizes

•Excellent hemodynamic performanceExcellent hemodynamic performance

•Growth potential Growth potential

•Non-immunogenicNon-immunogenic

•Minimal thrombo-embolismMinimal thrombo-embolism

•Low structural valve degeneration incidenceLow structural valve degeneration incidence


Transcatheter procedures in the young

Melody Pulmonary ValveMelody Pulmonary Valve

Bovine jugular veinBovine jugular vein

Platinum Iridium framePlatinum Iridium frame


Available Sutureless Prostheses

Enable (Medtronic)Enable (Medtronic)

Perceval (St Jude)Perceval (St Jude)

Intuity (Edwards Lifesciences)Intuity (Edwards Lifesciences)


Available transcatheter prostheses

Device Status Features

JENAVALVE(Jenavalve)

CE - TADevel. –TF

- anatomical orientation- partial repositioning

ENGAGER(Medtronic)

MC trial -TA no TF

- anatomical orientation- partial repositioning

ACURATE (Symetis)

CE - TAClin.trial –TF

- anatomical orientation- partial repositioning- intuitive positioning

PORTICO (SJM)

Clin.trial - TFDevel. - TA

- partial repositioning

SAPIEN 3 (Edwards)

Clin. Trial

-TF+TA- PV leak prevention


Transcatheter vs Sutureless AVR


Access routes for the young

2 cm

5 – 5.5 cm

Transapical Transfemoral Transaortic


TA: get as minimally invasive as TF

Percutaneous TA access & closure:

CardiApex

(1) small incisions + non rib spreading approach

(2) Validated access & closure devices

(3) Truly percutaneous? => Imaging!


Edwards Sapienexample: SAPIEN 3


TA- ACURATE (2011) Symetis


TA- Engager Medtronic


TAVR Complications

• Paravalvuar leakageParavalvuar leakage

• AV BlockAV Block

• MigrationMigration

• Leaflet dysfunctionLeaflet dysfunction

• Annulus rupturAnnulus ruptur

• Dissection/ perforationDissection/ perforation

• Coronary obstructionCoronary obstruction

• Mitral valve dysfunctionMitral valve dysfunction


TAVI

ResultsResults


Cohorte B Mortality


Cohorte A Mortality

Echocardiographic Findings (AT)Echocardiographic Findings (AT)

Numbers at RiskNumbers at Risk

TAVRTAVR 301301 269269 223223 210210 139139

AVRAVR 290290 224224 162162 151151 110110

Val

ve A

rea

(cm

2 )

TAVR

AVR

p = 0.002 p = 0.003 p = 0.16p = 0.001

Echocardiographic Findings Echocardiographic Findings Mean and Peak Gradients (AT)Mean and Peak Gradients (AT)


TAVRTAVR 307307 275275 233233 218218 144144

AVRAVR 295295 228228 168168 155155 112112

Gra

dien

t (m

mH

g)

Peak Gradient - TAVR

Mean Gradient - TAVR

Peak Gradient - AVR

Mean Gradient - AVR

Paravalvular AR and MortalityParavalvular AR and MortalityTAVR Patients (AT)TAVR Patients (AT)

None - Trace

Mild - Moderate - Severe

Months Post Procedure

Mor

talit

y


None-TrNone-Tr 167167 149149 140140 126126 8787 4141 1616

Mild-Mod-SevMild-Mod-Sev 160160 134134 112112 101101 6464 2626 1212

29.5%

14.5%

39.5%

24.8%

HR [95% CI] =2.01 [1.38, 2.92]

p (log rank) = 0.0002

Total AR and MortalityTotal AR and MortalityTAVR Patients (AT)TAVR Patients (AT)

Months Post Procedure

Mor

talit

y


None-TrNone-Tr 135135 125125 115115 101101 6868 3131 1111

MildMild 165165 139139 121121 111111 7171 3333 1616

Mod-SevMod-Sev 3434 2525 2222 1919 1515 66 22

None - Trace

Mild

Moderate - Severe 50.7%

26.3%

33.4%35.3%

12.7%

26.2%

p (log rank) < 0.001

GARY

Christian W. HammKerckhoff Heart and Thorax Center Bad Nauheim and

Medical Clinic I, University of Giessen, Germany

One-year outcomes of transcatheter aortic valve implantation in 9.111 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

German Aortic Valve RegistrY


TAVI Valve Type

transapicaltransapicaltransvasculartransvascular

n = 2.632 n =6.479

Medtronic55.9%

Edwards41.3%

Others2.8%

Others2.3%JenaValve

6.1%

Edwards79.1%

Medtronic3.5%

Symetis9.0%

CoreValve™

SAPIEN™

SAPIEN™

Engager™

ACURATE™

™


1-year follow-up: Stroke

1-year follow-up: interviewed patientsStroke

1,7%

2,3%2,0% 1,8%

1,3%

2,8%2,1%

1,8%

0%

1%

2%

3%

4%

5%

without CABG with CABG transvascular transapical

Minor StrokeMajor Stroke

TAVISurgical AVR

n = 5421 n = 2718 n = 1782 n = 715


GER 2011Mandatory AQUA Quality assessment

AKL Score(Risikogruppen)

Conv. AV Surgeryexpected observed

T-AVIexpected observed

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 %

Courtesy of Prof. Welz

lower than expected mortality higher than expected mortality


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


Conclusion

Less invasive procedures are the future

In low risk consider suture less AVR

In high risk consider TAVR

TA: The FRONT DOOR approach


Thank you for your attention!

[email protected]


no personal financial disclosures

KERCKHOFF HERZ- UND THORAXZENTRUM Transcatheter/Hybrid Aortic Valves in the Young Prof. Dr. Mirko...

Documents

Transcript of KERCKHOFF HERZ- UND THORAXZENTRUM Transcatheter/Hybrid Aortic Valves in the Young Prof. Dr. Mirko...