Surgery For Aortic Stenosis


Published on

State of the art aortic valve surgery in the era of percutaneous valve interventions. (invited lecture 2009)

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Congenital aortic valve (AV) disease. A, A normally functioning bicuspid AV with two commissures and the two leaflets, which are almost equal in size in a 58-year-old man who died of metastatic lung carcinoma. The commissures are located right and left and both coronary ostia arise from the anterior aortic sinus. Note the absence of raphe in either leaflet. The right coronary artery is denoted by an arrow; the left coronary artery is denoted by an arrowhead.
  • *By KM. Put n= for access complications in TA. Show vascular complication learning slide – old data vs. SOURCE. We figured it out with TF, now we can figure it out with TA. At 30 days: 369 patients at risk TF; 442 at risk TA At 30 days: TF<20 ES at Day 0 (n at risk 169) at 1 mo (n at risk 138); TF >20 ES at Day 0(281) at 1 mo (n at risk 223) At 30 days: TA<20 ES at Day 0 (n at risk 167) at 1 mo (n at risk 121); TF >20 ES at Day 0(394) at 1 mo (n at risk 312) Vascular complications (major and minor and major alone) not significant predictors of mortality EuroSCORE is significant predictor. See numbers and ROC curve. M&O have requested that we look into technical failure vs. outcome to get to the bottom of the question “If procedure goes well and patient dies – why?”
  • Surgery For Aortic Stenosis

    1. 1. Surgical options for aortic stenosis F MAISANO
    2. 2. Evolving scenario of valve disese <ul><li>Aging / Increased life expectancy </li></ul><ul><li>Changing style of life </li></ul><ul><ul><li>Quality of life over longevity </li></ul></ul><ul><ul><li>Productivity </li></ul></ul><ul><ul><li>E sthetic appearance </li></ul></ul><ul><li>Circulation of information </li></ul><ul><ul><li>Patients awareness </li></ul></ul><ul><ul><li>Referral pattern </li></ul></ul><ul><li>Limited resources / cost containment </li></ul>
    3. 3. AVR: state of the art <ul><li>about 300.000 operations/yr </li></ul><ul><li>More than 40 years of clinical experience </li></ul><ul><li>Prostheses are reliable </li></ul><ul><li>Predictable and low risks </li></ul><ul><li>Long term results available </li></ul>
    4. 5. STS DATABASE AVR n 32,968 Mortality 4.0% Stroke 1.5% Prolonged Ventilation 7.07% Reoperation 4.12% Renal Failure 3.7%
    5. 6. MedPAR Data
    6. 7. Long term Outcomes Eichinger et al Annals thorac Surg 2008 Durability Survival
    7. 8. TAVI: a new tool for the high risk patients
    8. 9. Aortic valve surgery in the era of TAVI <ul><li>TAVI as a complementary procedure for patients with contraindications </li></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><li>Technical </li></ul></ul><ul><li>TAVI as an alternative procedure </li></ul><ul><ul><li>High risk </li></ul></ul><ul><ul><li>Moderate risk </li></ul></ul><ul><ul><li>Low risk </li></ul></ul><ul><li>AVR in the context of TAVI </li></ul><ul><ul><li>Prosthesis choice </li></ul></ul><ul><ul><li>timing </li></ul></ul>
    9. 10. Technical contraindications <ul><li>Previous chest radiation </li></ul><ul><li>Porcelain aorta </li></ul><ul><li>Multiple previous sternotomies (esp. with open grafts) </li></ul>
    10. 11. Clinical contraindications <ul><li>Age </li></ul><ul><li>Euroscore, STS score </li></ul><ul><li>Severe comorbidities </li></ul><ul><ul><li>Liver failure </li></ul></ul><ul><ul><li>Renal failure (dialisis) </li></ul></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Neoplasia </li></ul></ul><ul><li>frialty </li></ul>
    11. 12. 30% of elderly patients are denied surgery
    12. 13. Age and mortality Euroscore logistic risk for valve surgery assuming no comorbidities
    13. 14. Aging epidemics <ul><li>According to the EC, the number of european citizens aged 75yrs or more is going to be 64M in 2025 </li></ul>x 4 x 7 IIASA, committee of the ECC, 2007
    14. 15. Prevalence of valve disease: AS is epidemic in the elderly Nkomo et al , Lancet 2006
    15. 16. Risk benefit analysis in the elderly
    16. 17. Evaluation of operative risk <ul><li>Risk </li></ul><ul><ul><li>Operative mortality </li></ul></ul><ul><ul><li>Morbidity </li></ul></ul><ul><ul><ul><li>Short term </li></ul></ul></ul><ul><ul><ul><li>Long term </li></ul></ul></ul><ul><li>Benefit </li></ul><ul><ul><ul><li>Survival </li></ul></ul></ul><ul><ul><ul><li>Quality of life </li></ul></ul></ul>
    17. 18. Common comorbidities in older patients Condition implications Renal dysfunction Exacerbated by diuretics and ACE inhibitors Chronic lung disease Contributes to uncertainty about diagnosis /volume status Cognitive dysfunction Interferes with dietary, medication, activity compliance Depression , social isolation Worsen prognosis, interferes with compliance Postural hypotension, falls Exacerbated by vasodilators, diuretics,  blockers Urinary incontinence Aggravated by diuretics, ACE inhibitors (cough) Sensory deprivation Interferes with compliance Nutritional disorders Exacerbated by dietary restrictions Polypharmacy Compliance issues, drug interactions Frailty Exacerbated by hospitalization; increased fall risk
    18. 19. How do you define debility or fraility ? <ul><li>Same age and predicted risk </li></ul><ul><li>One passes the “eyeball test”; one doesn’t </li></ul><ul><li>Fraility Index </li></ul>
    19. 20. Frailty of the elderly <ul><li>Reduction of organ reserve </li></ul><ul><ul><li>Reduced resistance to injury </li></ul></ul><ul><ul><li>Reduced adaptability </li></ul></ul><ul><li>Reduced physical activity </li></ul><ul><li>Reduced neurocognitive function </li></ul><ul><li>Depression </li></ul>
    20. 21. High to moderate risk <ul><li>Risk of surgery </li></ul><ul><li>Risk of TAVI </li></ul>
    21. 22. Aortic Valve Surgery Predictive Risk Algorithms <ul><li>STS </li></ul><ul><li>EuroSCORE (additive) </li></ul><ul><li>EuroSCORE (logistic) </li></ul><ul><li>Ambler (UK) </li></ul><ul><li>Northern New England </li></ul><ul><li>New York State </li></ul><ul><li>Providence Health System </li></ul>
    22. 23. Problems with Risk Algorithms <ul><li>All risk algorithms are based on operated patients and don’t factor in “inoperable “ patients </li></ul><ul><li>Outcomes other than mortality are not predicted, e.g., stroke, discharge disposition, QoL </li></ul><ul><li>Many risk variables not included </li></ul>
    23. 24. Variables Not Included In Risk Algorithms In Patients Undergoing AVR <ul><li>Previous chest radiation </li></ul><ul><li>Oxygen dependence </li></ul><ul><li>Reoperative patients with open grafts </li></ul><ul><li>Previous tissue valve replacement </li></ul><ul><li>Porcelain aorta </li></ul><ul><li>Advanced liver disease/cirrhosis </li></ul><ul><li>Degenerative neurocognitive disorders- Alzheimer’s </li></ul><ul><li>Frailness or debility </li></ul>
    24. 26. Euroscore overestimates the actual risk in the high risk population Osswald B, et al. European Heart Journal (2009) 30, 74–80
    25. 27. Leontyev et al Ann Thorac Surg 2009
    26. 28. Risk of TAVI <ul><li>Ascending aorta aneurysm </li></ul><ul><li>Uneven or massive valve calcification </li></ul><ul><li>Bicuspid valve </li></ul><ul><li>Previous mitral valve prosthesis </li></ul><ul><li>Access issues </li></ul><ul><li>Severe renal failure </li></ul>
    27. 29. Bicuspid vs tricuspid valve
    28. 30. Bicuspid Aortic Valve
    29. 31. Valve area and calcium detection
    30. 32. TAVI screening di 22
    31. 33. Valve Team Hsr Nov 2007-May 2009 82 TAVI 69 Transfemoral approach 10 Transapical approach 3 Trans-subclavian approach
    32. 34. Patient baseline clinical characteristics (n=82)
    33. 35. Procedural outcomes (n=82)
    34. 36. Survival Actuarial survival at 12 months: 88.1±4.3%
    35. 37. The SOURCE Registry Cohort One Survival Survival of TA pts with ES< and >20 are significantly different (93.4 vs. 88.1) (p=0.067) TF (n=459) TA (n=571) 30 day 93.7% 89.7% EuroSCORE <20 94.6% (Mean 12.5) 93.4% (Mean 12.4) EuroSCORE >20 93.3% (Mean 33.7) 63% of pts 88.1% (Mean 36.3) 70% of pts 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Fraction of Months post Procedure Survival < 20 >= 20 SOURCE 30 Day All Cause Mortality -- Transfemoral Approach Stratified by Logistic EuroSCORE SOURCE 30 Day All Cause Mortality -- Transapical Approach Stratified by Logistic EuroSCORE 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Fraction of Months post Procedure Survival < 20 >= 20 p=0.068
    36. 38. Patients entering the VALVETEAM screening process (n=181)
    37. 39. TAVI vs Surgical AVR
    38. 40. Challenging clinical scenarios <ul><li>Bicuspid valves </li></ul><ul><li>CAD + AS </li></ul><ul><li>Non severe AS in pts undergoing CABG </li></ul><ul><li>Renal failure patients </li></ul><ul><li>Dye allergy </li></ul><ul><li>Health economics </li></ul>
    39. 41. Current surgical candidates <ul><li>Minimization of invasiveness </li></ul><ul><ul><li>To mitigate risks </li></ul></ul><ul><ul><li>Increase acceptance </li></ul></ul><ul><li>Tailored treatment </li></ul><ul><ul><li>Anatomical substrate </li></ul></ul><ul><ul><li>Underlying disease </li></ul></ul><ul><ul><li>Patient needs </li></ul></ul><ul><li>Perioperative care </li></ul><ul><li>Pain management </li></ul><ul><li>Best prosthetic material </li></ul>
    40. 42. Surgical Approaches: Conventional and Minimally Invasive Cardiac Surgery Conventional Minimally Invasive
    41. 43. Minimally invasive surgery <ul><li>Mini-incisions </li></ul><ul><li>Abolition of CPB </li></ul>
    42. 44. Conventional and Minimally Invasive Incisions Mitral Valve Surgery Aortic Valve Surgery
    43. 45. Soft Tissue Retractor Placement – Used For Exposures in Minimally Invasive Cardiac Surgery
    44. 46. Level 3: Robotics <ul><li>Femoral Arterial & Venous Cannulation </li></ul><ul><li>Optional Direct Cannulation With Straight Shot Cannula </li></ul><ul><li>IJ Coronary Sinus Catheter </li></ul><ul><li>IJ Pulmonary Vent </li></ul><ul><li>EndoClamp Occlusion Balloon </li></ul><ul><li>Only Mitral Valve Replacements, Mitral Valve Repairs, ASDs & CABG Can Be Done At This Time </li></ul>
    45. 47. Trans-incision Visualization – The Aortic Valve
    47. 49. Barnett et al JTCVS 2009
    48. 50. The revalving concept
    49. 51. Expanding durabilty
    50. 52. Is valve device industry investing in surgical AVR? <ul><li>Minimally invasive approaches </li></ul><ul><li>Sutureless valve </li></ul><ul><li>No anticoagulation </li></ul><ul><li>More durable tissue valves </li></ul><ul><li>Exchangeable valves </li></ul>
    51. 54. Valve-X-change: the lifetime valve
    52. 56. Zlotnick et al Circulation 2008
    53. 57. Apicoaortic conduits
    54. 58. Edwards SAPIEN ™ THV
    55. 59. Subclavian access (Corevalve TM) <ul><li>Short delivery distance </li></ul><ul><li>Painless </li></ul><ul><li>Local anesthesia </li></ul><ul><li>Retrograde approach </li></ul>
    56. 60. conclusions <ul><li>Aortic stenosis can be treated with low risk in different ways </li></ul><ul><li>Percutaneous and transcatheter modalities are emerging </li></ul><ul><li>Guidelines will be revised </li></ul><ul><li>Open mind and collaborative efforts are key </li></ul><ul><li>Clinical wisdom is today the only tool available to guide the decision </li></ul>