Post on 19-Aug-2020
transcript
5/24/2017
1
Juan Crestanello, MDDivision of Cardiac Surgery
TAVR or SAVR: Beyond the STS Score
1
Lakshmi Prasad Dasi, PhDDepartment of Biomedical Engineering
The Ohio State UniversityWexner Medical Center
Disclosures
Dr. Dasi
▪ NIH/NHLBI
▪ NIH/NIBIB
▪ NIH/NCAI
▪ AHA
Dr. Crestanello Research Grants from: Medtronic Boston Scientific Abbot Vascular
2
5/24/2017
2
Patient Selection for SAVR vs TAVR
ExtremeInnoperable
Risk
High Risk
TAVR
Intermediate Risk
LowRisk
SAVR
Risk ProfileSTS PROM + Frailty + Other Comorbidities
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
Bicuspid Aortic Valve
LVOT Calcification
Small root-low lying coronary ostia
5/24/2017
3
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
Bicuspid Aortic Valve
LVOT Calcification
Small root-low lying coronary ostia
Age and Life Expectancy: Longer Survival
6
32
24
17
8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
Survival General Population
Survival after Surgical AVR
Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 2000
5/24/2017
4
Surgical Valve Durability
7
Freedom from Structural Valve Deterioration: Surgical AVR
Bourguinion et al. Ann Thorac Surg 2015
10-15 years
Age and Life Expectancy: Longer Survival
8
32
24
17
8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
Survival General Population
Survival after Surgical AVR
Freedom From SVD: Surgical AVR
Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 2000
5/24/2017
5
Age and Life Expectancy: Longer Survival
9
32
24
17
8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80S
urvi
val (
Yea
rs)
Age
Survival General Population
Survival after Surgical AVR
32% 21% 12% 3%
REOPERATION
Freedom From SVD: Surgical AVR
Social Security Life Tables Birkmeyer et al. Ann Thorac Surg 2000
10
TAVR Durability
5/24/2017
6
TAVR Durability
11
Age and Life Expectancy: Longer Survival
12
32
24
17
8
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
21
1511
6
0
10
20
30
40
50 60 70 80
Sur
viva
l (Y
ears
)
Age
Survival General Population
Survival after Surgical AVR
Freedom From SVD: TAVR
HIGHER REOPERATION
RATE
5/24/2017
7
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Ascending aortic aneurysms
Other
Valve and Aortic Root Anatomy
LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Ascending aortic aneurysms
Other
Valve and Aortic Root Anatomy
Annular and LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
5/24/2017
8
15
Annular and LVOT Calcification
Valve UnderexpansionParavalvular LeakAnnular Rupture
LVOT Calcification
16
Annular and LVOT Calcification
Paravalvular Leak- opposing side
5/24/2017
9
17
Annular and LVOT Calcification
Aortic View Annular View
Finite element modeling
Crimping stores energy into the nitinol valve frame
Valve frame does work to push calcified leaflets open
18
Annular and LVOT Calcification
Stent conformation over calcification results in flow paths
Potential for predictive modeling to optimize
Placement
Device selection
5/24/2017
10
19
Annular and LVOT Calcification
Computational Fluid DynamicsSimulation
Potential to couple fluids simulations with finite element modeling for pre-operative planning
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
Annular and LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
5/24/2017
11
Small Root – Low Lying Coronary Ostia
1-3% of population
More common in women
21
Small Root – Low Lying Coronary Ostia
22
The flow area for coronary bound flow can be complex due to:
Height, calcification, and width
Simulations and/or geometrically aligned indices better predict than just height
5/24/2017
12
Small Root – Low Lying Coronary Ostia
23
Device specific variation in leaflet position
Possible room for device selection and coronary protection for inoperable patients
Cylinder PorticoCoreValve
Moving Beyond Risk
Age-Life Expectancy-Valve Durability
Concomitant cardiac disease
Mitral valve disease
Coronary artery disease
Valve and Aortic Root Anatomy
LVOT Calcification
Small root-low lying coronary ostia
Bicuspid Aortic Valve
5/24/2017
13
Bicuspid Aortic Valve
2-3% of population
More common in the young
20% elderly patients with AS
25
Bicuspid Aortic Valve
Asymmetric cusps
More calcified
Asymmetric calcification
More circular annulus
Larger
Sinuses of Valsalva
STJ
Ascending aorta
26
Philip et al Catheterization and Cardiovascular Interventions 2015
5/24/2017
14
Bicuspid Aortic Valve
Device under-expansion
Higher rate of
Paravalvular leak
Second device
Annular rupture
Conversion to surgery
Improved with newer devices
Simulations?
Fate of the ascending aorta?
27
Yoon et al JACC 2015
Summary – So what is beyond STS score?
Clinical outcomes
Durability
Concomitant diseases
Mitral, Coronary, Other
Valve and Aortic Root Factors LVOT Calcification Low Lying Ostia Bicuspid
28
Directly impacts hemodynamics and
valve durability
5/24/2017
15
Acknowledgement
WMC Structural Heart Group – esp. Jennifer Dollery
Doctoral Students: Amir Azimian, Hoda Hatoum, Atieh Yousefi
Funding: NIH, DHLRI-Trifit
29