This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Coronary artery calcification (CAC) results in reduced vascular compliance, abnormal vasomotor responses, and impaired myocardial perfusion.
The presence of CAC is associated with worse outcomes in the general population and in patients undergoing revascularization
Two recognized types of CAC are
Atherosclerotic (Intimal)
Medial artery calcification
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
Coronary artery calcification (CAC) results in reduced vascular compliance, abnormal vasomotor responses, and impaired myocardial perfusion.
The presence of CAC is associated with worse outcomes in the general population and in patients undergoing revascularization
Two recognized types of CAC are
Atherosclerotic (Intimal)
Medial artery calcification
Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease is found in 4 to 6 percent of all patients who undergo coronary arteriography. When present, it is associated with multivessel coronary artery disease about 70 percent of the time
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en farmacología en intervencionismo
Antonio Fernández Ortiz (Hosp. Clínico San Carlos. Madrid)
Cardiogestión
Casa del Corazón
Madrid 15 de septiembre de 2016
Actualización de los nuevos anticoagulantes orales en base a datos en práctica clínica real
Domingo Marzal Martín
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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TAVR SAVR evolution of a groundbreaking therapy
1. TAVR
Evolution of a Groundbreaking Therapy
LUIS A. RAMIREZ-VALDIVIA MD
CTS FELLOW
October 8, 2020.
2. Aortic Valve stenosis
-Most Common Valvular Heart
Disease
-Prevalence ~5% in population >75
yrs.
-30% Symptomatic patients not
eligible for Surgical Replacement.
-Ancona A. e-Journal of Cardiology Practice .2020.Vol. 18, N° 10 - 12
-Praz, F, Siontis, G. et.al. Curr Opin Cardiology. 2017; 32:2.
3. Historical Background:
1992
• Henning Rud
Andersen:
• First report
Animal
implant of a
Transcatheter
Heart Valve
1995
• Patent
granted
2002
• Alain Cribier:
• First in
Human TAVR
4
Kumar, Vinayar. J Am Heart Assoc. 2020;9:e015921
European Heart Journal, Volume 13, Issue 5, May 1992, Pages 704–708,.
4. History: First TAVR in human
April 16 2002.
-57 yr old male, EF 12%,
-PMH:
-Lung cancer (lobectomy, 1999)
-Chronic pancreatitis
-Subacute leg ischemia (eventual cause of death 4 months
after TAVR)
-Recurrent schock after Balloon AV angioplasty.
-Performed ANTEGRADE (femoral vein-transeptal)
Cribier, Alain. Glob Cardiol Sci Pract. 2016 Dec 30; 2016(4): e201632
5. 2002-2004: Single Centre Feasibility
Trials
Rouen, FR: trials on 38 patients restricted to
compassionate use (imminent death).
- 80% PROCEDURAL SUCCESS rate (trans septal
approach)
-High (25%) incidence of > grade 2 paravalvular
regurgitation : need to develop larger size
bioprosthesis ( >23 mm).
-Cribier A. J Am Coll Cardiol. 2004;43:698–703.
- Cribier A. J Am Coll Cardiol. 2004;43:698–703.
-Cribier A. J Am Coll Cardiol. 2006;47:1214–23.
6. 2004 Edwards & Medtronic :
Gamechanger
-Easier delivery system
-New approaches were developed
- 2004 Medtronic : CoreValve
◦ Auto-expandable nitinol frame +
porcine pericardial valve
◦ Transfemoral approach
◦ Smaller sheath sizes (21F then 18F)
than those required for Edwards
devices (22F and 24F).
◦ The Conformité Européenne (CE)
approval for both models in 2007.
Cribier, Alain. Glob Cardiol Sci Pract. 2016 Dec 30; 2016(4): e201632
7. 2003-2006: Multi Center Feasibility
Alternate Approaches
Genereaux, P. et.al. European Heart Journal (2012) 33, 2388–2400
~80%succes
rate
11. PARTNER I: Design
Leon, MB, Smith CR, et.al. N Eng J Med . 2010. 363; 17: 1597-1607.
Cohort A
Cohort B
12. PARTNER IB: Results
Leon, MB, Smith CR, et.al. N Eng J Med . 2010. 363; 17: 1597-1607.
∆ =
−𝟏𝟗%
−𝟐𝟐. 𝟑%
13. PARTNER IA: Results
Smith, CR. Et.al. N Engl J Med 2011; 364:2187-2198
Similar outcomes vs
SAVR for High Risk
Patients
14. Given PARTNER B Cohort Results:
No comparison vs Inoperable
patients.
-Compared Mortalitiy rate after
CoreValve at 1 yr vs an estimated
Mortality Rate with Medical
treatment (set as 43%). Included
489 patients.
JACC Vol. 63, No. 19, 2014 Popma et al. May 20, 2014:1972–81
CORE VALVE
15. 30 d 1 Yr
TAVR SAVR TAVR SAVR
All Cause Death +Stroke (%) 3.3 4.5 14.2 19.1
MACCE (%) 7.7 10.4 20.4 27.3
Major Stroke (%) 3.9 3.1 5.8 7.0
Permanent Pacemaker (%) 19.8 7.1 22.3 11.3
Major Vasc Complic (%) 5.9 1.7 6.2 2.0
Core Valve: results in High Risk Patients
Adams, DH, Popma, JJ. et.al. N Engl J Med 2014. 370; 19
Statistically significant for
superiority in primary End point
16. 5 years later… Trend Remain
SAPIEN
-Death Rate
◦ Inoperable: (TAVR 71.8% vs 93.6%
in SAVR)
◦ High Risk: No difference
-Aortic Regurgitation
◦ Moderate to severe: 14% TAVR vs
1% SAVR)
Kumar et.al. J Am Heart Assoc. 2020; 9:e015921
Core Vave
-Death Rate
◦ High Risk: similar (55.3 vs 55.4%)
-Aortic Regurgitation
◦ Moderate to severe: 50% TAVR vs
23% SAVR)
-Permanent PM : TAVR 33 % VS
19.8% SAVR
17. TAVR Superior to Non
Inferior to Standard
Medical therapy in High
Risk patients.
TAVR Superior to
Standard Medical
therapy in Non
operable patients.
20. PARTNER 2: Results
-No Significant
difference at 24
months for Primary
Endpoint.
(21 vs 18.9%)
-Major Vascular
complications at 2 yrs:
TAVR 8.6 vs SAVR 5.5%.
TAVR more associated
with Aortic
Regurgitaion
Leon MB, Sith CR. Et.al. N Engl J Med 2016. 374;17
21. SURTAVI (2017):
Intermediate Risk
TAVR vs SAVR (respectively):
-All cause death + Disabling stroke:
12.6 vs 14% (nss)
-Rehospitalization:
13.2 vs 9.7 % (ss)
-Aortic Valve Reintervention:
2.8 vs 0.7% (ss).
Non inferior
Reardon, MJ. N Engl J Med 2017; 376:1321-1331
Intermediate Risk:
TAVR NON INFERIOR
Each proceddure has a different
Adverse event Profile
26. PARTNER 3:
Multicenter Randomized Trial
Low Risk definition: Agreement by Heart Team as <4% risk of death within 30 days of
procedure.
Important considerations:
-Primary endpoint : Composite of
All Cause Mortality, Disabling Stroke or Rehospitalization at 1 year
-PPM and Aortic Regurgitation not considered Key Secondary Endpoints
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
27. PARTNER 3: Low Risk. SAPIEN 3 Valve
1000 patients from 71 sites
Treated : 950 pt
-496 TAVR
-454 SAVR
Follow Up planned for 10
years.
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
28. PARTNER 3:
Low Risk
Baseline TAVR -SAVR
-Mean Age: 73 Yrs
-Male 68 and 71%
-STS score 1.9%
-EuroSCORE II: 1.5
-NYHA III/IV: 31 vs 23%
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
29. PARTNER 3: Results
At 1 year TAVR vs SAVR:
Primary Endpoint: Death, Stroke or
Rehospitalization:
8.5 vs 15.1%
Requirements for both Noninferiority
and Superiority were met: difference
between the TAVR group and the SAVR
group of −6.6 %
(95% [CI], −10.8 to −2.5; P<0.001 for noninferiority) and a HR of 0.54
(95% CI, 0.37 to 0.79; P=0.001 for superiority)
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
30. PARTNER 3: Results
CONTROVERSY: Most of the Advantage for TAVR in the COMPOSITE given by Lower
Rehospitalization inclusion??
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
31. PARTNER 3: Key Secondary Endpoints
TAVR:
-Less New A fib
-Shorter LOS
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
32. PARTNER 3: Other Secondary Endpoints
New Permanent
Pacemaker (%)
>Moderate PV Aortic
Regurgitation (%)
Vascular
Complications (%)
30 d 1 yr 30 d 1 yr 30d 1 yr
SAVR 4.0 5.4 0.0 0.5 1.5 1.5
TAVR 6.5 7.3 0.8 0.6 2.2 2.8
Mack, MJ, Leon MB. N Engl J Med 2019; 380:1695-1705
Less PVL and PPM (no difference to SAVR)
33. PARTNER 3: Conclusions
TAVR:
-Non Inferior and Superior(*) for Primary endpoint.
-Similar to SAVR for Death for any cause
-Significant Less Stroke Risk
-Much less PPM and PVL
34. Evolut Low Risk Trial
-Low Risk Definition:
No more than a predicted 3% risk of death
by 30 days with surgery, as assessed by
members of the local heart team.
-Primary end point:
Composite of Death from any cause or
Disabling stroke at 24 months
-Used 3 Generations of devices: CoreValve,
Evolut R, or Evolut PRO.
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
FIGURES
Figure S1. Self-Expanding Transcatheter Heart Valves
CoreValve Evolut R Evolut PRO
3.6% 74.1% 22.3%
35. Evolut Low Risk Trial
Baseline TAVR vs SAVR
- Age 74 yrs
-Male 64 vs 62%
-STS PROM 1.9%
-NYHA III/IV: 25.1 vs 28.4%
-LVEF 61%
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
36. Evolut Low Risk Trial
*Additional patients were randomized to permit completion of the LTI substudy and to enroll a Japanese cohort.
Patient Flow
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
37. Evolut Low Risk Trial : RESULTS
-Composite of Death from
any cause or Disabling stroke
at 24 months TAVR vs SAVR
5.3 vs 6.7% (Not Inferior, Not
Superior)
-Less Disabling stroke at 24
months
1.1 vs 3.5%
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
38. Evolut Low Risk Trial : RESULTS
Stroke:
Similar in both
groups, slightly
favors TAVR.
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
39. Evolut Low Risk Trial : RESULTS
New Permanent Pacemaker
(%)
>Moderate PV Aortic
Regurgitation (%)
Vascular Complications
(%)
30 d 1 yr 1 Yr 2 yr 30d 1 yr
SAVR 6.1 6.7 1.5 0 3.2 3.5
TAVR 17.4 19.4 4.3 5.8 3.8 3.8
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
40. Evolut Low Risk Trial : RESULTS
Marginally Better
Hemodynamic Performance
for TAVR
Clinical Significance to be
determined
41. Figure S4: New York Heart Association Class Over Time (As-Treated Population)
Baseline 30 Days 1 Year
No. (%)
TAVR
N=725
Surgery
N=678
TAVR
N=706
Surgery
N=625
TAVR
N=428
Surgery
N=342
NYHA I 76 (10.5) 63 (9.3) 545 (77.2) 416 (66.6) 336 (78.5) 279 (81.6)
NYHA II 467 (64.4) 422 (62.2) 149 (21.1) 179 (28.6) 84 (19.6) 59 (17.3)
NYHA III 181 (25.0) 190 (28.0) 12 (1.7) 29 (4.6) 7 (1.6) 4 (1.2)
NYHA IV 1 (0.1) 3 (0.4) 0 (0.0) 1 (0.2) 1 (0.2) 0 (0.0)
REFERENCES
Evolut: Other Secondary Endpoints
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
-Comparable
Improvement in
Functional Class.
42. Evolut Low Risk :Conclusions
TAVR:
-Not Inferior and Not Superior to SAVR for Primary Endpoint
-Better Hemodynamic Performance
SAVR:
-Less new PPM
-Less PVL
Similar Stroke and vascular complications Rates
Popma JJ, Deeb GM. N Engl J Med 2019; 380:1706-1715
he first patient was a 57-year old male patient in cardiogenic shock, with multiple comorbidities previous lung cancer, chronic pancreatitis and sub-acute leg ischaemia due to recent occlusion of aorto-femoral bypasses. His LVEF was 12% and he had been declined by 3 cardiac surgery teams. The patient was transferred from the University Hospital in Lille for an emergency balloon aortic valvuloplasty. There was some hemodynamic improvement with BAV, but a recurrence of shock at 48 hours. This was followed by a discussion about attempting the first percutaneous valve replacement. Both the family and the patient agreed to this idea immediately. The percutaneous heart valve team accepted the challenge, despite the very high risk, as this was the only possible option to save this young patient’s life.