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Dr Indran RamanathanCardiothoracic Surgeon
MercyAscot Hospital
8:30 - 9:25 WS #107: Is TAVI under LA the Best Choice for Severe Aortic Stenosis?
9:35 - 10:30 WS #119: Is TAVI under LA the Best Choice for Severe Aortic Stenosis? (Repeated)
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AORTIC STENOSIS UPDATE:
WHAT THE GP NEEDS TO KNOW
GPCME Rotorua 2019
Indran Ramanathan MBBS, PhD, FRACS, FCSANZ
Cardiothoracic Surgeon
Auckland City Hospital
Mercy Hospital
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Overview
Cardiac Anatomy
Cardiovascular Physiology
Clinical signs and symptoms
Prognosis
Treatment Option
Surgical Aortic Valve Replacement
Transcatheter Aortic Valve Implantation (TAVI)
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Aortic Stenosis: Needs a Team
The patient
GP
Cardiologist
Echocardiogram
Interventional Cardiologist
Cardiothoracic Surgeon
Anaesthetist, Intensivist
Geriatrician
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Cardiac Anatomy
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Cardiac Anatomy
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Aortic Valve Disease
Aortic Stenosis
Calcification
Rheumatic
Bicuspid Valve (1-2%
of general population)
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Aortic Stenosis
Pathophysiology
LV outflow obstruction
Increased LV pressure
◼ Chronic LV hypertrophy
Increased LV stiffness
◼ Increased LVEDP
◼ Dependent on atrial contraction to
fill
◼ AF not well tolerated
Fixed cardiac output
Symptoms
Angina
SOB
Syncope
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Aortic Stenosis
Symptoms Median Survival
Angina 5 years
Syncope 3 years
Congestive Heart Failure 2 years
1 year survival 57% once symptoms develop
Aortic Valve Replacement
Recommended for all symptomatic patients
10 year survival post-AVR 75%
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Aortic Stenosis
Signs
Anacrotic Pulse
◼ Weak pulse
Ejection Systolic Murmur
◼ Aortic Area: Left sternal edge
◼ Louder with expiration
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Prevalence of AS
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The problem is urgent
➢ Survival after onset of symptoms is 50% at two years and 20% at five years1
➢ “…valve surgery is appropriate with even mild symptoms.”2
Aortic stenosis is life-threatening and progresses rapidly
Sources
1) Catherine M. Otto. Valve Disease: Timing of Aortic Valve Surgery. Heart. 2000;84:211-218.
2) Catherine M. Otto. Valvular Aortic Stenosis Disease Severity and Timing of Intervention. AMJC. 2006;47:2141-51.
Chart: Ross et al. Aortic stenosis. Circ.1968;38 (Suppl 1):61-7.
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“Cancer” of the Aortic Valve
BMC Cancer 2016 16:381
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Medical School Review!
Aortic stenosis: LV outflow obstruction
Symptoms: Angina, SOB, Syncope
Signs: ESM, weak pulse
Dramatic increase in prevalence > 75 year olds
Prognosis without treatment: 1 year survival 50%
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When we knew What we know
Aortic Stenosis
1937
◼ Symptoms
1968
◼ Prognosis
Average age at death
◼ 63 years old
Pts were symptomatic
◼ 50’s and 60’sEugene Braunwald 1968
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Patients are much older today
Eugene Braunwald 2018
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How do older patients present?
Increasing tiredness
“slowing down”
“getting older”
Limit activity to their ability
Close questioning may reveal SOB
Auscultation: Usually ESM
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Surgical Aortic Valve Replacement
Trans-catheter Aortic Valve Implantation
Treatment of Aortic Stenosis
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Mechanical or Bioprosthetic AVR
Free from Structural deterioration
Need warfarin
INR 2.5-3.5
Survival Advantage
Pts <55 years old
No anticoagulation
Structural Valve Deterioration
More rapid deterioration with younger pts
Approx 15yr freedom from deterioration
Mechanical Bioprosthetic
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Surgical Outcomes
STS Adult Cardiac Surgery Database – Period Ending 06/30/2010
Executive Summary
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Surgical Outcomes in Octogenarians
Auckland City Hospital Experience
2007-2011
68 octogenarians (mean age 83.2yrs): surgical AVR
Operative Mortality 0% (predicted mortality 4.9%)
1yr survival 95.2%
3yr survival 90.1%
5yr survival 75.3%
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AVR survival comparable to age-matched
population
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
% S
urv
ival
Years
Survival after AVR for severe aortic stenosis
Age and gender-matchedMinnesota population
Survival after AVR
Source: Morgan L. Brown et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2008;135(2):308-315.
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AVR in asymptomatic patients?
The Journal of
Thoracic and Cardiovascular Surgery
The benefits of early valve replacement in asymptomatic patients with
severe aortic stenosis
Morgan L. Brown, Patricia A. Pellikka, Hartzell V. Schaff, Christopher G. Scott,
Charles J. Mullany, Thoralf M. Sundt, Joseph A. Dearani, Richard C. Daly and
Thomas A. Orszulak
J Thorac Cardiovasc Surg 2008;135:308-315
DOI: 10.1016/j.jtcvs.2007.08.058
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://jtcs.ctsnetjournals.org/cgi/content/full/135/2/308
Source: Morgan L. Brown et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2008;135(2):308-315.
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Methods applied in 15-year study
➢ 622 patients
➢ Aged 72 ± 11 years
➢ Isolated asymptomatic severe aortic stenosis
➢ Peak systolic velocity of > 4 m/s by transthoracic
echocardiography
➢ Monitored for the onset of symptoms and need for AVR
Source: Morgan L. Brown et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2008;135(2):308-315.
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Survival benefit in surgically treated patient cohort
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
% S
urv
ival
Years
Patient survival
AVR, no Sx
AVR, Sx
No AVR, no Sx
No AVR, Sx
Source: Morgan L. Brown et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2008;135(2):308-315.
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THE ANNALS OF
THORACIC SURGERY
Severe Aortic Stenosis in a Veteran Population: Treatment Considerations and
Survival
Faisal G. Bakaeen, Danny Chu, Mark Ratcliffe, Raja R. Gopaldas, Alvin S. Blaustein,
Raghunandan Venkat, Joseph Huh, Scott A. LeMaire, Joseph S. Coselli and Blase A.
Carabello
Ann Thorac Surg 2010;89:435-458
DOI: 10.1016/j.athoracsur.2009.10.033
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://ats.ctsnetjournals.org/cgi/content/full/89/2/453
Source: Faisal G. Bakaeen et al. Severe Aortic Stenosis in a Veteran Population: Treatment Consideration and Survival. Ann Thorac Surg. 2010;89:453-458.
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Survival rate of patients was higher in
AVR group vs medically managed
0%
20%
40%
60%
80%
100%
Survival RatesYear 1
Survival RatesYear 3
Survival Ratesyear 5
Survival Rates: Surgical vs. Medical
AVR patients
Medical patients
Source: Faisal G. Bakaeen et al. Severe Aortic Stenosis in a Veteran Population: Treatment Consideration and Survival. Ann Thorac Surg. 2010;89:453-458.
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News you can use…
Remember Aortic stenosis
SOB, Angina, Syncope
Older patients with vague symptoms
50% 1 year survival without treatment
Auscultation
Murmur
Heart check once in 12 months: all pts over 50yrs
Done at time patient presents for prostate check, Pap smear, mammogram, colonoscopy
Echocardiogram
Referral: ?symptomatic aortic stenosis
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Timing of Treatment
Disease
Progression
Non-Surgical
CandidateSurgical EvaluationAsymptomatic
Low Risk Surgical Candidate High Risk Surgical Candidate
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Trans-catheter Aortic Valve Implantation (TAVI)
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❑ Stainless steel frame
❑ Leaflets made from bovine pericardium
❑ Deployed by expanding a balloon
❑ A “skirt” limits leakage around valve
Sapien 3 Transcatheter
Valve(Edwards)
On delivery
system
Deployed by
balloon
expansion
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Trans-catheter Aortic Valve Implantation
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Surgical AVR or TAVI
Sternotomy
CPB
ICU, longer Hospital stay and recovery
Mechanical Valve possible
Concomitant surgery
CABG, MVR, AF
Local anaesthetic and sedation
2-3 day hospital stay
Quick recovery
Cost
Surgical AVR TAVI
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Trans-catheter Aortic Valve Implantation
First TAVI 2002
Dr Alain Cribier; Rouen, France
◼ 57yo severe AS, cardiogenic shock, EF 12%
◼ Too high risk for surgical AVR
◼ Successful TAVI
◼ “resurrection”, died 4 months later
TAVI access
Trans-femoral
Trans-apical, Trans-aortic
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Multiple RCTs of TAVI
TAVI vs Standard Treatment in High Risk Non-Surgical candidates◼ TAVI superior to medical treatment
TAVI vs AVR in high risk surgical candidates◼ TAVI non-inferior to surgical AVR
TAVI vs AVR in intermediate risk surgical candidates◼ TAVI non-inferior to surgical AVR
TAVI vs AVR in low risk surgical candidates◼ TAVI superior in as-treated composite end-point of death and stroke
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INTRA TAVI PROCEDURES
Jim Stewart FRACP, John Ormiston FRACP,
Indran Ramanathan PhD FRACS
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Baseline Patient Characteristics
Intra Core Valve Intra Edwards Intra allPatients 40 110 150Mean age (Range) 84.2 (44-94) 82.4 (64-95) 82.9 (44-95)Median age 85.3 83 83.9Male 63% 65% 65%Female 37% 35% 35%
Average EuroScore II (SD) 22.2 (12) % 7.8 (7.2)% 13.4 (11.7) %Range EuroScore 5-52% 1-41% 1-52%Median Euro Score IQR 18.3 (14,27) % 5.8 (3, 9)% 9.4 (4,18) %Average STS Score (SD) 6.4 (3.2) 5.2 (2.7) 5.4 (2.8)Range STS Score (Core n=9) 1-10.5% 1.43-13.4% 1-13.4%
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Baseline Patient Characteristics
Intra Core Valve
Intra Edwards Intra all
NYHA class III or IV 93% 47% 46%Previous CABG 28% 22% 23%Previous CVA / TIA 11% 15% 17%Diabetes 20% 15% 17%COPD 18% 11% 13%CKD>3 56% 42% 50%Permanent Pacemaker 13% 9% 10%
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Baseline Echo Cardiology
Intra Core Valve
Intra Edwards Intra all
Mean AV gradient - mmHg (mean+SD) 49 + 15 44 + 13 44 + 13
AV Area - cm (mean+SD) 0.7 + 0.24 0.9 + 0.68 0.8 + 0.59
LV Ejection Fraction <30% 0% 5% 4%
LV Ejection Fraction 30-50% 32% 18% 22%
Mod-Severe AR - % 35% 7% 15%
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Procedural Factors
Intra Core Valve
Intra Edwards Intra all
BAV (%) 97% 40% 45%
Mean procedure time (mins) 80 (49-143) 58 (24-164) 64 (24-164)
>1 Valve Implanted (%) 0 0 0
Valve Embolization (%) 0 0 0
Convert to open surgery (%) 0 0 0
Conscious Sedation (%) 0 71% 52%
Median length of stay - Days (IQR) 7 (5,9) 3 (2, 4) 4 (2,6)
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Procedural Factors
Intra Core Valve
Intra Edwards first 55 patients
Intra Edwards second 55 patients
Mean procedure time - Minutes (Range) 80 (49-143) 67 (36-164) 48 (24-113)Mean length of stay - Days (Range) 7 (4-23) 4 (1-23) 2 (1-6)Median length of stay - Days (IQR) 6 (5,9) 3 (2, 5) 2 (2,3)
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30 Day Outcomes
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Survival
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TAVI or Surgical AVR in NZ
TAVI costs: $NZ 70-80k
Surgical AVR cost: $NZ 45-50k
Aim: Cost-effective treatment
DHBs and Insurers
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Funding for TAVI in NZ?
High risk non-surgical patients: Not funded
High risk surgical: Fundedafter discussion with heart team
Intermediate and Low Risk: Not funded
High risk non-surgical patients: Funded if expected survival >2yrs
High & Intermediate risk surgical: Funded after discussion with heart team
Low Risk: Not funded
Public Sector Private Sector
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Take Home Messages….
Remember Aortic stenosis
SOB, Angina, Syncope
Older patients with vague symptoms
50% 1 year survival without treatment
Auscultation
Murmur
Heart check once in 12 months: all pts over 50yrs
Done at time patient presents for prostate check, Pap smear, mammogram, colonoscopy
Echocardiogram
Referral: ?symptomatic aortic stenosis
Treatment options: Surgical or TAVI; depend on the risk profile
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Thank you!
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AORTIC STENOSIS UPDATE:
WHAT THE GP NEEDS TO KNOW
GPCME Rotorua 2019
Indran Ramanathan MBBS, PhD, FRACS, FCSANZ
Cardiothoracic Surgeon
Green Lane CTSU
Auckland City Hospital
Mercy Hospital
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TAVI Outcomes: Partner A
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Aortic Regurgitation
Aetiology
Abnormalities of Valve Leaflets
◼ Rheumatic
◼ Endocarditis
◼ Bicuspid Valve
Dilation of Aortic Root
◼ Aortic Aneurysm / Dissection
◼ Annuloaortic ectasia
◼ Marfan’s Syndrome
Symptoms
SOBOE
Fatigue
Decreased exercise tolerance
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Aortic Regurgitation
Pathophysiology
Abnormal flow of blood from the aorta into the LV
Acute
◼ Normal LV size
◼ Volume load leads to raised LVEDP
◼ Transmitted to LA and pulmonary circulation
Chronic
◼ LV dilates to accommodate regurgitant volume
◼ Asymptomatic for a long time
◼ Eventual systolic dysfunction
◼ Angina secondary to increased wall tension
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Aortic Regurgitation
Asymptomatic patients
Follow-up, periodic echo, antibiotic prophylaxis
60% asymptomatic pts with normal LV function remain
asympyomatic at 10yrs
Asymptomatic patients with reduced LV function
Valve Surgery
Symptomatic patients
Valve surgery