1. TAVI: Asian Perspective NUHS National University Health System NUHS National University Health System

2. Aortic stenosis in Singapore Tay et al. SMJ 2012 (In press)

3.  Mean logistic euroscore: 10.7+/-12.3  Refusal rate for open heart surgery 42.2% Tay et al. SMJ 2012 (In press)

4. Unique challenges in Asian cohorts  Smaller annulus sizes  Smaller femoral sizes  Smaller LV cavity size  More frail?

5. Aortic root dimensions Total (n=249) Degenerative (n=216) Rheumatic (n=11) Bicuspid (n=22)P value Aortic dimensions Annulus 20.3 ±2.0 20.2 ±1.9 20.7 ±1.3 21.2 ±2.5 0.045 Sinus 32.3 ±5.0 30.5 ±1.4 33.1 ±4.8 0.67 STJ 26.6 ±5.2 26.5 ±5.4 24.7 ±2.1 27.9 ±3.6 0.50 Ascending Ao 33.9 ±5.9 33.6 ±6.0 30.2 ±4.2 36.4 ±4.6 0.11 Upper Ascending Ao 35.3 ±6.0 35.4 ±6.2 33.1 ±3.0 35.3 ±6.0 0.88 Tay et al. SMJ 2012 (In press)

6. Int J Cardiol 2012 (In press) Males Females Unique challenges in Asian cohorts Smaller femoral sizes

7. PatientAge Ethic group Gender STS score EFeGFRCo-morbidities 172MalayFemale2.42547Cardiac cachexia 293EurasianMale147018Chronic obstructive lung disease. 380ChineseMale3.15060 Co-existent severe mitral regurgitation and low boy weight (BSA1.4) 482MalayMale4.23338Limited mobility from bilateral OA knee 586IndianMale5.27040Limited mobility from bilateral OA knee 661ChineseMale7.33510Previous CABG with patent saphenous vein grafts 784ChineseFemale8.84551 Previous Ca breast with radiation. Low body weight 884ChineseMale4.76547Limited mobility 988ChineseMale3.07060Concomittant thoracic aneurysm requiring TEVAR 1078ChineseFemale47554BSA 1.4 (small size). Cardiac cachexia 1192ChineseFemale12.46950 1282IndianMale11.87041On chronic immune suppression 1373ChineseMale6.33060Previous CABG with patent saphenous vein grafts 1479ChineseFemale7.76047Limited mobility and obesity Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

8. Patient Annulus (mm) Femoral artery size (mm) Access Site Valve size Length of stay (days) PVLMR 30 day mortality 1194.1TA2315TrivialModerate►Mild-modNil 2244.4TA2652MildMild (unchanged)Nil 3217.4TF2310TrivialSevere►mod severeNil 4246.4TF2670*MildMild to mod►mildNil 5217.2TF236Mild-ModMild (unchanged)Nil 6235.2TA269MildMild (unchanged)Nil 7205.6TA238NoneMild (unchanged)Yes 8208.3TF236MildMild-mod►mildNil 9247.8TF2617Mild-ModMild (unchanged)Nil 10234.8TA2612NoneMild (unchanged)Nil 11216.2TF2310MildMild►mild-modNil 12216.3TF2317MildTrivial (unchanged)Nil 13246.2TA267TrivialMild to mod►mildNil 14216.5TF2333*MildMild (unchanged)Nil Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

9. Improved functional class Reduction in mean gradient Tay and Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

10. Patient selection  Patients are determined to be high risk by two cardiac surgeons  Reviewed by TAVI team  Decision on TAVI and access

11. TAVI workup  Traditional Coronary angiogram and right heart catheterization+/- PCI Transthoracic and Transesophageal echocardiogram CT coronary angiogram+aortogram (including ileofemorals) US carotids, PFT, usual pre-op labs Determine angles of implant on the on day of procedure

12.  Currently: Using CT to plan implant angles (if CT available) Using DynaCT if implant angles not available Using DynaCT and overlays if aortic aneurysms present

14. Challenges (1)  With diagnostic CT Pre-procedural CT with difficult imaging in tachycardic patients/those who are in failure/AF Renal failure patients an contrast concerns (differences in Asian cohorts)

15. Challenges (2)  DynaCT Need for rapid pacing and significant volumes of contrasts ‘static’ overlays

16. The ideal situation  Pre-procedure:Minimize pre-procedural scanning/testing eg (1 test provide annulus size, ileofemoral sizes, angle of implant, coronary arteries, calcium volume) Powerful pre-processing software  Less contrast/less pacing  ‘Dynamic/Live’ overlays Safe and effective procedural imaging

17. Education Research Clinical

18.  First in Asia series published  Maintain the highest quality of care for valvular heart disease patients  Standards and outcomes audited according to international TAVI benchmarks

19. Education  Providing training for transcatheter aortic valve implantation in Singapore  Providing training to new operators and regional centres in TAVI  Incorporating TAVI and hybrid OT technologies in imaging/interventional meetings  Fellowship and residency programmes

20. Research  Diagnostic imaging (CT for sizing in access sites Asian patients)  Novel biomarker research into aortic stenosis and TAVI  Clinical trials and test site for second generation TAVI valves  Asian database for valvular heart disease

21. Thank you