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

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

3. 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

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

5. Long Term Survival

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

7. 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

8. 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

9. 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:

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

11. 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:

12. 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:

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

14. 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%

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

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

17. 30 Day Mortality Suri et al. Ann Thorac Surg. 2015;100:2136-45
Divr et al. J Am Coll Cardiol 2014;63:269–79

18. 30 Day Outcomes
Suri et al. Ann Thorac Surg. 2015;100:

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

20. 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:

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

22. Rate of Rehospitalization
Holmes et al JAMA. 2015;313:

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

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

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

26. 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: /jamacardio

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

28. 30 Day Outcomes after TAVR
CLD is associated with:
Similar mortality
Longer ICU and hospital stay
More discharge to extended care facilities

29. 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

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

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