Surgery or percutaneous aortic valve replacement, what is the best?
ď “
History
The first successful surgical replacements of diseased human
heart valves were reported in 1960.
We have been forced to rely on observational studies of patients receiving prosthetic valves.
Despite that, the effect of aortic valve replacement on survival was un-doubtful.
History
Effects of aortic valve replacement on survival Schwarz et al. Circulation, November 1982.
Natural history of aortic stenosis
ď “ Ross J, Braunwald E. Aortic stenosis, circulation 1968;38.
Natural history of aortic stenosis
ď “ Ross J, Braunwald E. Aortic stenosis, circulation 1968;38.
ACC/AHA Guidelines for Treatment of AS Aortic Valve Replacement (AVR) is a Class I indication in symptomatic patients with severe AS
>30% of Patients with Severe Symptomatic AS are “Untreated”!
First in man implantation
Building the clinical evidence
PARTNER B 2 year: All cause mortality (ITT)
PARTNER A Trial
PARTNER A Trial
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PARTNER A Trial
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Cost effectiveness TF vs AVR
Cost effectiveness TF vs AVR
Cost effectiveness TA vs AVR
Cost effectiveness TA vs AVR
How to decrease complications in TAVR?
Core valve 30 day mortality
Core valve 30 day stroke rate
Stroke following SAVR and TAVR
Core valve vascular complications
TAVR 2002-2012
November 2, 2011
FINALLY…we’re off and running!
TAVR 2002-2012
FDA approves “high surgical risk” indication for transcatheter Sapien heart valve (both TF and TA)
October 19, 2012
AND NOW…we’re catching up!
Can we extend the indications to lower risk surgical patients?
JACC 2012;59
RCT TAVI vs. SAVR Intermediate risk Medtronic SURTAVI Edward PARTNER II
RCT TAVI vs. SAVR Intermediate risk
RCT TAVI vs. SAVR Intermediate risk
Summary
TAVI is transformational technology for suitable patients
with symptomatic severe AS who are inoperable or high risk for SAVR. The impact of TAVI on both quality and quantity of life is
profound, but it is not free of potential complications. Expanding the indications to intermediate risk patients will
be answered by SURTAVI and PARTNER II in the future.
Summary
ď “ TAVI or SAVR
does not matter?
ď “ Multidisciplinary team approach ( cardiac surgeon,
interventional cardiologist, echocardiographer, imaging, anesthesia) benefits patients.