Controversias: TAVI - Dr. Lino Patricio
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Transcript of Controversias: TAVI - Dr. Lino Patricio
ControversiaEstenosis aórtica riesgo moderado
Intermediate risk aortic StenosisTAVI
Lino Patricio, MD,PhDH.S.Marta Lisbon
H.S.E.S. ÉvoraPortugal
Coronary TreatmentRecent Cardiology History
1970/
1980
1990/
2000
2000/
2005
2005/2008
2008 20102010/2015
CASS/VACABG
SVGFailure
BMS/ISRLIMA
ARTS-II/CABGPCI/CABG
ARTSERACI-II
SoSMASS-II
PCI/CABG
DESNo ISR No DM
LIMA/ECC
SYNTAX
FAME
TAXUSSYNTAXScore
FFR-PCI
COURAGECarminzid
OMTSAT
FAME-2
DES-2;3 GSyntax
Funtional
Intervention enthusiasm
FREEDOM
OCTIVUS
Surgery Enthusiasm
ITT population
P=0.048
8.8%0
Months Since Allocation
Cum
ula
tive E
vent
Rate
(%
)
TAXUS (N=903)CABG (N=897)
Coronary TreatmentAll-Cause Death to 4 Years
25
50
Before 1 year*
3.5% vs 4.4%P=0.37
1-2 years*
1.5% vs 1.9%P=0.53
2-3 years*
1.9% vs 2.6%P=0.32
3-4 years*
2.2% vs 3.2%P=0.22
11.7%
0 12 4824 36
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
Aortic Valve TreatmentRecent Cardiology History
1970/
1980
1990/
2000
2000/
2005
2005/2008
2008 20102010/2015
Intervention enthusiasmSurgery Enthusiasm
Valve Prosthesis
Balloon Valvuloplasty
TAVI
Aortic Repair
0
100
200
300
400
500
600
700
800
900
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
TAVI number of publications
Pubmed
Publications / week
0
5
10
15
20
25
30
TAVI CTO Mitral
AHA/ACC Valvular Heart Disease Guidelines
170Leon M.B., Smith C.R., Mack M., et al; Transcatheter aortic-valveimplantation for aortic stenosis in patients who cannot undergosurgery. N Engl J Med. 2010;363:1597-1607.
171Makkar R.R., Fontana G.P., Jilaihawi H., et al; Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012;366:1696-1704
172Smith C.R., Leon M.B., Mack M.J., et al; Transcatheter versus surgicalaortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187-2198.
173Murphy E.S., Lawson R.M., Starr A., et al; Severe aortic stenosisin patients 60 years of age or older: left ventricular function and 10–yearsurvival after valve replacement. Circulation. 1981;64:II184-II188.
Aortic stenosisHigh Risk patients
CoreValve US Pivotal Trial
12
13
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
CoreValve US Pivotal Trial
SAVRTAVR
CoreValve US Pivotal TrialProcedural Outcomes
SAVRTAVR
CoreValve US Pivotal TrialAortic Gradient
Aortic Regurgitation
Results
Hemodynamic Assessment of Percutaneous Versus Surgical Bioprostheses for Aortic Stenosis During Exercise: A Pilot Study
P=0,0019 para repouso e p= 0,01 para pico de esforçoP=0,003 para repouso e p= 0,004 para pico de esforço
Prostheses Aortic GradientDuring Exercise
Intermediate risk aortic Stenosis
8,2
9,4
7,6 7,6 7,5
6,9
6
5,3
9,7
8,05
7,15
6,1
5,35,5
5
0
1
2
3
4
5
6
7
8
9
10
2006 2007 2008 2009 2010 2011 2012 2013
Vancouver Quebec
Evolution of STS in Vancouver and Quebec
Mediana STS
417 P
Intra Hospital MortalityQuebec
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2007-08 2009 2010 2011 2012 2013
vivos Muertos
15% 19% 8.5%4% 6% 3%
Coronary TreatmentRecent Cardiology History
ICP begun with simple cases and it was not competitive with surgery - with complex cases never
was better than surgery
1970/
1980
1990/
2000
2000/
2005
2005/2008
2008 20102010/2015
CASS/VACABG
SVGFailure
BMS/ISRLIMA
ARTS-II/CABGPCI/CABG
ARTSERACI-II
SoSMASS-II
PCI/CABG
DESNo ISR No DM
LIMA/ECC
SYNTAX
FAME
TAXUSSYNTAXScore
FFR-PCI
COURAGECarminzid
OMTSAT
FAME-2
DES-2;3 GSyntax
Funtional
Intervention enthusiasm
FREEDOM
OCTIVUS
Surgery Enthusiasm
Aortic Valve TreatmentRecent Cardiology History
1970/
1980
1990/
2000
2000/
2005
2005/2008
2008 20102010/2015
Intervention enthusiasm
Surgery Enthusiasm
Valve Prosthesis
Balloon Valvuloplasty
TAVI
Aortic Repair
TAVI begun with complex cases and it was competitive with surgery - with simple cases will be better than surgery
Por primera vez en la historia de la intervención un tratamiento percutáneo fue mejor que la cirugía
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
• Untreated Severe AS
• Asymptomatic Severe AS
• AS + CAD / previous surgery
• Bioprosthetic Valve Failure
• Patient (> 75 years old) refusal
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
Resultados
Eventos Intra-hospitalares na Substituição Valvular Aórtica Percutânea Versus Cirúrgica numa Amostra Emparelhada
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart TeamPropensity score matching
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
• Untreated Severe AS
• Asymptomatic Severe AS
• AS + CAD / previous surgery
• Bioprosthetic Valve Failure
• Patient (> 75 years old) refusal
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
Patients with an AV-Vel 5.5 m/s had an event-freesurvival of 44%, 25%, 11%, and 4% at 1, 2, 3, and 4 years, Patients with an AV-Vel between 5.0 and 5.5 m/s had a even free survival of 76%, 43%, 33%, and 17% (P<0.0001).
Rosenhek, R. et al. Circulation 2010;121:151-156
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
• Untreated Severe AS
• Asymptomatic Severe AS
• AS + CAD / previous surgery
• Bioprosthetic Valve Failure
• Patient (> 75 years old) refusal
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
• Untreated Severe AS
• Asymptomatic Severe AS
• AS + CAD / previous surgery
• Bioprosthetic Valve Failure
• Patient (> 75 years old) refusal
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
TAVI
Patient Selection
Heart Team
/ previous surgery/ previous surgery
• Untreated Severe AS
• Asymptomatic Severe AS
• AS + CAD / previous surgery
• Bioprosthetic Valve Failure
• Patient (> 75 years old) refusal
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
No High Risk Aortic Stenosis PatientsSelection Criteria
Heart Team
Por primera vez en la historia de la medicina un tratamiento percutáneo fue mejor que la cirugía
Inoperable patient selection criteria Strict Perspectiveis an historical, unadjusted option
The Strict Board criteria excluded the patients morefavorable to TAVI and don’t have ethical strength toexclude patients with heavy comorbidities not suitablefor any type of intervention (TAVI or AVR)
TAVI
Patient Selection
Heart Team
Time trends in transaortic mean gradient
Gurvitch, R. et al. Circulation 2010;122:1319-1327
Time trends in aortic valve area (mean{+/-}SD)
TAVI
Patient Selection
Heart Team