Niv Ad, MD Chief, Cardiac Surgery Professor of Surgery, VCU

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Presentation transcript:

Decision Making In Aortic Stenosis From Surgical AVR with Sutured or Sutureless Valves to TAVI Niv Ad, MD Chief, Cardiac Surgery Professor of Surgery, VCU Inova Heart and Vascular Institute

Disclosures Niv Ad: Medtronic Inc. - Consultant Atricure Inc.- Consultant Sorin - Consultant Left Atrial Appendage Occlusion LLC – Co Owner

A Few Observations

The Heart Valve Team

Who is going to have it?

Who is going to have it?

The Importance PVL

The SJD Portico Trial Reduced leaf mobility?

What Are the Key Questions Associated with Patients Selection ? Can we base our policies on a few industry sponsored studies ? (even if prospective randomized) What is the weight of biological (comorbidities) and anatomical variables ? How important are? Lower diameter and aggressive crimping Newer valve designs not requiring a cage Native valve

What Are the Key Questions Associated with Patients Selection ? Can we base our policies on a few industry sponsored studies ? (even prospective randomized) What is the weight of biological (comorbidities) and anatomical variables ? How important are? Lower diameter and aggressive crimping Newer valve designs not requiring a cage Native valve

What Are the Key Questions Associated with Patients Selection ? Can we base our policies on a few industry sponsored studies ? (even prospective randomized) What is the weight of biological (comorbidities) and anatomical variables ? How important are? Lower diameter and aggressive crimping Newer valve designs not requiring a cage Native valve

JTCVS 2014

Over 80 years Old Perioperative Outcomes (STS <3%) AVR/CABG N=47 Isolated AVR N=41 Deep Sternal Wound Infection Perioperative MI Septicemia 1 (2%) Prolonged Ventilation (24 h) 2 (4%) 2 (5%) Pneumonia Permanent Stroke TIA Reoperation for Bleeding GI Renal Failure Renal Failure Requiring Dialysis Operative Mortality Readmission <30 Days 4 (8.5%) 3 (7%)

Two-Year Survival (STS <3%) AVR/CABG N = 47 Isolated AVR N = 41

Two-Year Survival (STS <5%) AVR/CABG N = 144 Isolated AVR N = 89

Perceval S – Bovine Percardium and Nitinol stent

Freedom from Re-Operation

What Are the Key Questions Associated with Patients Selection ? Can we base our policies on a few industry sponsored studies ? (even prospective randomized) What is the weight of biological (comorbidities) and anatomical variables ? How important are? Lower diameter and aggressive crimping Newer valve designs not requiring a cage Native valve

What Are the Key Questions Associated with Patients Selection ? Can we base our policies on a few industry sponsored studies ? (even prospective randomized) What is the weight of biological (comorbidities) and anatomical variables ? How important are ? Lower diameter and aggressive crimping Newer valve designs not requiring a cage Native valve

The Impact of TAVR on Patients Selection for SAVR

The Impact of TAVR on Patients Selection for SAVR 8.8% 2.2% 2.3%

Summary With the availability of a novel treatment option for aortic stenosis in high-risk patients, institutions offering these alternative methods will be forced to reevaluate patient management. A careful strategy that includes multidisciplinary evaluation is crucial in order to have a successful transcatheter aortic valve program.

Conclusions Sutureless Aortic valve is significant in: Reducing operating time Minimally invasive procedure Ease of implant (control variability) Long term outcomes are unknown PVL Durbility

The Heart Valve Team

But

Conclusions Low risk patients including older patients should have SAVR regardless the number of sutures Special considerations: Anatomy (Calcium and Bicuspid) Frailty Renal Failure CAD Redo procedures

THANK YOU