dr indran ramanathan - gp cme north/sat_room8_0830_tavi gpcme 20… · avr, sx no avr, no sx no...

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)

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

Overview

Cardiac Anatomy

Cardiovascular Physiology

Clinical signs and symptoms

Prognosis

Treatment Option

Surgical Aortic Valve Replacement

Transcatheter Aortic Valve Implantation (TAVI)

Aortic Stenosis: Needs a Team

The patient

GP

Cardiologist

Echocardiogram

Interventional Cardiologist

Cardiothoracic Surgeon

Anaesthetist, Intensivist

Geriatrician

Cardiac Anatomy

Cardiac Anatomy

Aortic Valve Disease

Aortic Stenosis

Calcification

Rheumatic

Bicuspid Valve (1-2%

of general population)

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

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%

Aortic Stenosis

Signs

Anacrotic Pulse

◼ Weak pulse

Ejection Systolic Murmur

◼ Aortic Area: Left sternal edge

◼ Louder with expiration

Prevalence of AS

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.

“Cancer” of the Aortic Valve

BMC Cancer 2016 16:381

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%

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

Patients are much older today

Eugene Braunwald 2018

How do older patients present?

Increasing tiredness

“slowing down”

“getting older”

Limit activity to their ability

Close questioning may reveal SOB

Auscultation: Usually ESM

Surgical Aortic Valve Replacement

Trans-catheter Aortic Valve Implantation

Treatment of Aortic Stenosis

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

Surgical Outcomes

STS Adult Cardiac Surgery Database – Period Ending 06/30/2010

Executive Summary

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%

AVR survival comparable to age-matched

population

0

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

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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.

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.

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.

Survival benefit in surgically treated patient cohort

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90

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

% S

urv

ival

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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.

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.

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.

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

Timing of Treatment

Disease

Progression

Non-Surgical

CandidateSurgical EvaluationAsymptomatic

Low Risk Surgical Candidate High Risk Surgical Candidate

Trans-catheter Aortic Valve Implantation (TAVI)

❑ 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

Trans-catheter Aortic Valve Implantation

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

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

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

INTRA TAVI PROCEDURES

Jim Stewart FRACP, John Ormiston FRACP,

Indran Ramanathan PhD FRACS

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%

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%

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%

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)

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)

30 Day Outcomes

Survival

TAVI or Surgical AVR in NZ

TAVI costs: $NZ 70-80k

Surgical AVR cost: $NZ 45-50k

Aim: Cost-effective treatment

DHBs and Insurers

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

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

Thank you!

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

TAVI Outcomes: Partner A

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

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

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