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Long-Term Outcomes Using a Long-Term Outcomes Using a Self-Expanding Bioprosthesis in Self-Expanding Bioprosthesis in Patients With Severe Aortic Patients With Severe Aortic Stenosis Deemed Extreme Risk Stenosis Deemed Extreme Risk for Surgery: Two-Year Results for Surgery: Two-Year Results From the CoreValve US Pivotal From the CoreValve US Pivotal Trial Trial Steven J. Yakubov, MD FACC For the CoreValve US Clinical Investigators

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Page 1: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Long-Term Outcomes Using a Self-Long-Term Outcomes Using a Self-Expanding Bioprosthesis in Patients With Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From Risk for Surgery: Two-Year Results From the CoreValve US Pivotal Trial the CoreValve US Pivotal Trial

Steven J. Yakubov, MD FACC For the CoreValve US Clinical Investigators

Page 2: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

DisclosuresDisclosures

TCT 2014

Steven J. Yakubov, MD FACC•Consultant to Medtronic: member of the CoreValve US Pivotal Trial screening, steering, and publications committees

2

Medtronic personnel performed all statistical analyses and assisted in the graphical display of the data

Page 3: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

BackgroundBackground

Popma JJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol 2014; 63: 1972-81.

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Page 4: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Pivotal Trial DesignPivotal Trial Design

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Page 5: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Primary EndpointPrimary Endpoint1-Year All-Cause Mortality or Major Stroke 1-Year All-Cause Mortality or Major Stroke

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Page 6: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

18F Delivery System

Study DeviceStudy Device

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4 Valve Sizes (18–29 mm annular diameter)

Page 7: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Study Disposition

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Page 8: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Analysis CohortAnalysis Cohort

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Page 9: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Participating SitesParticipating Sites

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Page 10: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

99.2% Follow-up 99.2% Follow-up (n=364/367)(n=364/367)

99.2% Follow-up 99.2% Follow-up (n=364/367)(n=364/367)

100% Follow-up 100% Follow-up (n=489/489)(n=489/489)

100% Follow-up 100% Follow-up (n=489/489)(n=489/489)

98.2% Follow-up 98.2% Follow-up (n=441/449)(n=441/449)

98.2% Follow-up 98.2% Follow-up (n=441/449)(n=441/449)

93.8% Follow-up 93.8% Follow-up (n=286/305)(n=286/305)

93.8% Follow-up 93.8% Follow-up (n=286/305)(n=286/305)

Study Compliance

100% Echo Performed 100% Echo Performed (n=489/489)(n=489/489)

100% Echo Performed 100% Echo Performed (n=489/489)(n=489/489)

96.4% Echo Performed 96.4% Echo Performed (n=433/449)(n=433/449)

96.4% Echo Performed 96.4% Echo Performed (n=433/449)(n=433/449)

91.6% Echo Performed 91.6% Echo Performed (n=336/367)(n=336/367)

91.6% Echo Performed 91.6% Echo Performed (n=336/367)(n=336/367)

Clinical AssessmentsEchocardiographic

Assessments

BaselineN=489

1 MonthN=449

84.9% Echo Performed 84.9% Echo Performed (n=259/305)(n=259/305)

84.9% Echo Performed 84.9% Echo Performed (n=259/305)(n=259/305)

2 YearsN=305

1 YearN=367

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Page 11: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Chairman: Michael J. Reardon, MD•Two clinical site cardiac surgeons and one interventional cardiologist determined patient eligibility•All patients were reviewed on web-based conference calls with site investigators to confirm eligibility and access route •Detailed portfolio included:

• STS PROM and all other risk factors • Independent review of transthoracic echocardiogram• Independent review of chest/abdominal CTA findings

• Two senior surgeons and one cardiologist on the screening committee had to concur with the local heart team assessment to qualify the patient for trial enrollment

National Screening CommitteeNational Screening Committee

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Page 12: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Baseline DemographicsCharacteristic, %

N=489

Age, years 83.2 ± 8.7

Male 47.9

STS Predicted Risk of Mortality 10.3 ± 5.5

Logistic EuroSCORE 22.6 ± 17.1

New York Heart Association class III/IV 91.8

Diabetes mellitus 41.5

Insulin requiring diabetes 18.4

Prior stroke 13.7

Coronary artery disease 81.8

Prior coronary artery bypass grafting 39.5

Prior percutaneous coronary intervention 37.0

Prior balloon aortic valvuloplasty 20.4

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Page 13: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Comorbidities, Frailty, Disabilities

Characteristic, % N=489

Prohibitive Anatomy

Severe aortic calcification* 17.2

Hostile mediastinum 11.9

Comorbidities

Severe chronic lung disease 23.5

Home oxygen 29.9

Frailty

Anemia with prior transfusion 22.8

Albumin < 3.3 g/dL 18.25-Meter gait speed > 6 secs 84.2

DisabilitiesAssisted living 27.6≥ 2 Katz ADL deficits 20.9Wheelchair bound 16.6

*Aorta calcification measured on screening CTATCT 2014 13

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CoreValve US Pivotal Trial Extreme Risk Iliofemoral 2-Year Results

Page 15: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

All-Cause Mortality or Major StrokeAll-Cause Mortality or Major Stroke

TCT 2014 15* Calculated rate for 117 events in 179 patients (65.4%, lower confidence bound of

57.9% by Exact method) (Makkar RR, et al, New Engl J Med, 2012)

Page 16: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

2-Year Mortality2-Year Mortality

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Page 17: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

17TCT 2014

2-Year Mortality2-Year MortalityLandmark Analysis Landmark Analysis

Page 18: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

2-Year Major Stroke2-Year Major Stroke

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Page 19: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

19TCT 2014

2-Year Major Stroke2-Year Major StrokeLandmark Analysis Landmark Analysis

Page 20: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Secondary EndpointsSecondary EndpointsEvents*, % 1 Year 2 YearsAny stroke 7.0 8.7

Major 4.3 5.1

Minor 3.2 4.1

Myocardial infarction 2.0 2.8

Reintervention 1.8 1.8

VARC bleeding 42.8 45.3

Life threatening or disabling 18.0 20.8

Major 28.3 29.1

Major vascular complications 8.4 8.4

Permanent pacemaker implant 26.4 28.9

Per ACC guidelines 19.5 22.0

* Percentages obtained from Kaplan Meier estimates

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Page 21: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

NYHA Class in 2-Year SurvivorsNYHA Class in 2-Year SurvivorsPaired AnalysisPaired Analysis

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Page 22: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Echocardiographic FindingsEchocardiographic Findings

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Page 23: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Paravalvular RegurgitationParavalvular Regurgitation

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Page 24: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

PVL and All-Cause MortalityPVL and All-Cause Mortality

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Page 25: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

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Pacemaker and All-Cause MortalityPacemaker and All-Cause Mortality

Page 26: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Subgroup Analysis Subgroup Analysis 2-Year All-Cause Mortality or Major Stroke2-Year All-Cause Mortality or Major Stroke

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Page 27: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

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Subgroup Analysis Subgroup Analysis 2-Year All-Cause Mortality or Major Stroke2-Year All-Cause Mortality or Major Stroke

Page 28: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

• At 2 years the CoreValve US Pivotal Extreme Risk Study showed: – Low rates of all-cause mortality– Low rates of major stroke– Improvement in NYHA classifications– Durable improvement in hemodynamic valve

performance (EOA and mean gradients)– Low rates of moderate or severe aortic

insufficiency– No association of mild or moderate paravalvular

regurgitation on mortality

ConclusionsConclusions

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Page 29: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

• The 1-year results from the CoreValve US Pivotal Extreme Risk Study support the safety and efficacy of this therapy in patients unsuitable for surgical AVR

• The 2-year results confirm the improved survival benefit in these patients

SummarySummary

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Page 30: Long-Term Outcomes Using a Self- Expanding Bioprosthesis in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery: Two-Year Results From

Thank YouThank YouOn Behalf of the CoreValve US Investigators


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