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