5th International Meeting on Aortic Diseases
Indications of TAVILuc Pierard, MD, PhD, FESC, FACC
Chair, ESC Working Group on Valvular Heart Diseases
Professor of Medicine
Head, Department of Cardiology
University Hospital Sart Tilman, Liège, Belgium
5th International Meeting on Aortic Diseases
No DisclosureLuc Pierard, MD, PhD, FESC, FACC
Chair, ESC Working Group on Valvular Heart Diseases
Professor of Medicine
Head, Department of Cardiology
University Hospital Sart Tilman, Liège, Belgium
Indications for TAVIESC/EACTS 2012 (new in 2017)
Class Level
TAVI should only be undertaken with a multidisciplinary “heart team” including
cardiologists and cardiac surgeons and other specialists if necessary.I C
TAVI should only be performed in hospitals with cardiac surgery on-site. I C
TAVI is indicated in patients with severe symptomatic AS who are not suitable for
AVR as assessed by a “ heart team” and who are likely to gain improvement in their
quality of life and to have a life expectancy of more than 1 year after consideration
of their comorbidities.
I B
TAVI should be considered in high risk patients with severe symptomatic AS who
may still be suitable for surgery, but in whom TAVI is favoured by a “heart team”
based on the individual risk profile and anatomic suitability.IIa B
European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 &
European Journal of Cardio-Thoracic Surgery 2012 -
doi:10.1093/ejcts/ezs455).
SAVR vs TAVI
ACC/AHA Guidelines 2014
The PARTNER 2A Trial
Leon et al N Engl J Med 2016;374:1609-20
Editorial and Correspondance
• Still a high-risk population (highest quintile of risk)
• Lower risk of AF and acute kidney injury
• Long-term effect of paravalvular AR?
• Effects of silent brain infarcts after TAVI?
• Antithrombotic therapy after stroke in SAVR group?
• Treatment of frequent concomitant MR?
Questions
• Is aortic stenosis severe?
• What is the surgical risk?
• Frailty?
• Size of the prosthesis?
• Access route?
Risk assessment (ACC/AHA 2014)
Scores
PARTNER RISK SCORE FRANCE 2 RISK SCORE
Higher creatinine Age ≥ 90 years
Oxygen dependant CLD BMI < 30 kg/m²
Lower mini-mental status Dialysis
Major arrhythmias (AF) Non transfemoral access
Lower mean gradient NYHA Class IV
Lower 6MWT distance ≥2 pulmonary oedema’s/yr
Pulmonary hypertension
Geriatric evaluation
• Define a « frailty index »
– Cognitive assessment and risk of delirium
– Nutritional status
– Functional assessment
• Gait speed > 1m/sec
Schoenenberger A.W et al. Eur Heart J. 2013;34(9):684-692.
The Current Management of AS
Otto CM, Prendergast B. N Engl J Med 2014;371:744-756.
Futility for TAVI?
• Reduced LVEF
• Low valve gradient, reduced stroke volume
• Significant mitral regurgitation
• Chronic kidney disease
• Pulmonary disease
• Pulmonary arterial hypertension
• Trends in aortic valve intervention in Germany 2007-2013• TAVI: 32,581, SAVR: 55,992 – TAVI cohort older and higher risk
• Falling mortality
• TAVI 13.2% to 5.4%
• SAVR 3.8% to 2.2%
• Reduction in
• Stroke
• Bleeding
• PPM requirement
• AKI
Reinohl J et al. N Engl J Med 2015;373:2438-2447.
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Current status of transcatheter valve therapy in Europe: results from an EAPCI survey
EuroIntervention June 2016 (on-line ahead of print)
2010
2011
2012
2013
2014
2015
2016
Published
Completion
Low Intermediate High Extreme
NOTION
PARTNER 3
US Evolut R LR
PARTNER 2A
SURTAVI
PARTNER 1A
Corevalve US HR
PARTNER 1B
Corevalve US ER
REPRISE 3
SAVR Risk
SALUS
PORTICO IDE
Medtronic CoreValve/Evolut R
Edwards Sapien/Sapien XT/Sapien 3
Boston Lotus
Direct Flow Medical Direct Flow
St. Jude Portico
PARTNER 2 S3i
UK TAVI
Any available TAVR system
2017
2018
2019
2016
REBOOT
CHOICE
TAVR UNLOAD
PARTNER 2 S3
Investigational devices
SOLVE-TAV
Recent and Ongoing TAVI Trials
Some Remaining Areas of Concern(and of particular relevance in younger, low risk patients)
• Durability and Leaflet Thickening
• Endocarditis
• Stroke
• Paravalvular Leak
• Permanent Pacemaker Requirements
• Non-Transfemoral Access
• Bicuspid Valves
Eurostat 2010
Percent of total population
We are all getting older…
Estimated Global TAVR Procedure Growth
SOURCE: Credit Suisse TAVI Comment –January 8, 2015. ASP assumption for 2024 and 2025 based on analyst model. Revenue split assumption in 2025 is 45% U.S., 35% EU, 10% Japan, 10% ROW
In the next 10 years, TAVR growth will increase X4!