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

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

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

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

Aortic root dimensions Total (n=249) Degenerative (n=216) Rheumatic (n=11) Bicuspid (n=22)P value Aortic dimensions Annulus 20.3 ± ± ± ± Sinus 32.3 ± ± ± STJ 26.6 ± ± ± ± Ascending Ao 33.9 ± ± ± ± Upper Ascending Ao 35.3 ± ± ± ± Tay et al. SMJ 2012 (In press)

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

PatientAge Ethic group Gender STS score EFeGFRCo-morbidities 172MalayFemale Cardiac cachexia 293EurasianMale147018Chronic obstructive lung disease. 380ChineseMale Co-existent severe mitral regurgitation and low boy weight (BSA1.4) 482MalayMale Limited mobility from bilateral OA knee 586IndianMale Limited mobility from bilateral OA knee 661ChineseMale Previous CABG with patent saphenous vein grafts 784ChineseFemale Previous Ca breast with radiation. Low body weight 884ChineseMale Limited mobility 988ChineseMale Concomittant thoracic aneurysm requiring TEVAR 1078ChineseFemale47554BSA 1.4 (small size). Cardiac cachexia 1192ChineseFemale IndianMale On chronic immune suppression 1373ChineseMale Previous CABG with patent saphenous vein grafts 1479ChineseFemale Limited mobility and obesity Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

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

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

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

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

 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

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)

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

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

Education Research Clinical

 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

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

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

Thank you