TAVR in Patients with Chronic Lung Disease Juan Crestanello, MD Division of Cardiac Surgery Wexner Medical Center The Ohio State University

Disclosure Juan Crestanello, MD Advisory Board: Medtronic   Disclosure Advisory Board: Medtronic Institutional Research Support: Abbot Vascular Boston Scientific

TAVR in CLD 82 y old male with SOB (NYHA class III) STS PROM: 10.2% FEV1: 875 ml (48% predicted) On Home O2, oral steroids, and inhalers LVEF: 55% Severe AS: Mean gradient: 45 mmHg Peak velocity: 4.2 m/s AVA 0.6 cm2

TAVR in CLD Should we do TAVR on this patient? Are we going to improve his survival? Is he going to feel better?

Long Term Survival

Long Term Survival AS vs.COPD Severe AS Medical Therapy 93% 68% 50% Kapadia et al Lancet 2015; 385: 2485–91

Long Term Survival AS vs.COPD Severe AS Medical Therapy 93% 68% 50% 18% Severe COPD 10% 3% Kapadia et al Lancet 2015; 385: 2485–91

Long Term Survival in COPD GOLD Classification 1: FEV1 ≥ 80% 2: FEV1 ≥ 50% to <80% 3: FEV1 ≥ 30% to <50% 4: FEV1 <30% Manino et at. Respiratory Medicine 2006; 100: 115–122

Surgical AVR STS Database: CLD in 25% PFTs in only 31% Among patients with PFTs, CLD in 50%: Mild: 25% Moderate:13% Severe:11% Patients with the most severe CLD were not offered surgery Crestanello et al Ann Thorac Surg. 2014;98:2068-77

Surgical AVR: Short Term Outcomes Crestanello et al Ann Thorac Surg. 2014;98:2068-77

Surgical AVR: Long Term Outcomes Survival Probability 65-69 y old 70-79 y old ≥80 y old 6 9 13 Brennan et al Circulation. 2012;126:1621-1629

Surgical AVR: Long Term Outcomes Survival Probability 65-69 y old 65-69 y old Severe CLD 5 13 Brennan et al Circulation. 2012;126:1621-1629

Surgical AVR: Long Term Outcomes Survival Probability ≥80 y old ≥80 y old Severe CLD 3 6 Brennan et al Circulation. 2012;126:1621-1629

TAVR: CLD Prevalence PARTNER Trial: 43% CoreValve US Pivotal Trial: 55% (70% PFTs) Mild: 20% Moderate: 13% Severe: 22% TVT Registry: 27% None-Mild: 72% Moderate: 14.2% Severe: 13.2%

CLD Patients Characteristics Younger Higher STS PROM More comorbidities NYHA class III-IV Smoking Oxygen dependency Suri et al. Ann Thorac Surg. 2015;100:2136-45

TAVR Outcomes Short and long term survival Re-hospitalization Functional status QOL

30 Day Mortality Suri et al. Ann Thorac Surg. 2015;100:2136-45 Divr et al. J Am Coll Cardiol 2014;63:269–79

30 Day Outcomes Suri et al. Ann Thorac Surg. 2015;100:2136-45

Long Term Survival Divr et al. J Am Coll Cardiol 2014;63:269–79 Suri et al. Ann Thorac Surg. 2015;100:2136-45

Risk Model for Mortality 30 Day Mortality 1 Year Mortality Edwards et al. JAMA Cardiol. 2016;1:46-52 Holmes et al JAMA. 2015;313:1019-1028

Divr et al. J Am Coll Cardiol 2014;63:269–79

Rate of Rehospitalization Holmes et al JAMA. 2015;313:1019-1028

Functional Status 75% 73% 60% Divr et al. J Am Coll Cardiol 2014;63:269–79

Functional Status Mok et al. J Am Coll Cardiol Intv 2013;6:1072–84

Quality of Life: KCCQ-OS 72±23 76±22 44±23 Arnold et al JAMA Cardiol. doi:10.1001/jamacardio.2016.5302

Quality of Life: KCCQ-OS Favorable Outcome: Alive KCCQ-OS ≥60 Stability or improvement in the KCCQ-OS from baseline to follow up (decrease of <10 points) Arnold et al JAMA Cardiol. doi:10.1001/jamacardio.2016.5302

KCCQ-OS Arnold et al JAMA Cardiol. doi:10.1001/jamacardio.2016.5302

30 Day Outcomes after TAVR CLD is associated with: Similar mortality Longer ICU and hospital stay More discharge to extended care facilities

One Year Outcomes after TAVR Moderate and Severe CLD is associated with: Decreased survival Increased hospital readmission Most patients with CLD experience Improvement in NYHA and 6 MWT Improvement in QOL indices

One Year Outcomes after TAVR Associated with 1 year mortality Frailty Pulmonary HTN Lower AV gradients at baseline

CHF and Airway Obstruction Magee et al Ann Thorac Surg 2013;96:1329–35