Track 7: TAVR Flashcards
Prevalance of AS
4% in ages 70-79
10% in ages 80-89
Generally speaking, based on age, what are the recommendations for aortic bioprosthesis versus mechanical?
< 50 yo: Mechanical
50-70 yo: shared decision making, either reasonable
(perhaps if under 55 mechanical better choice)
> 70(65) yo: biologic prosthesis
Typical longevity for biologic prostheses?
10-15 years
* less in younger patients and those with smaller aortic annulus size
* Higher rate of reoperation
* Degradation d/t immune mediated response
Outline some of the pros and cons of mechanical prostheses
Con:
- Lifelong anticoagulation
- Risk of hemorrhage (15% increased absolute of bleeding over 15 years, 1% per year)
- Risk of thromboembolism (5% increased absolute risk of stroke over 15 years)
Pros:
- Durability ~30+ years
Pt between 50-70(65) yo
Name some factors that would make mechanical valve preferable
Prosthetic valve preferable?
Mechanical:
- Able/willing to take A/C
- Low bleeding risk
- Good longevity
- Normal lifestyle
- High risk 2nd operation
Prosthetic:
- Unable/unwilling to take A/C
- High bleeding risk
- Limited longevity
- Extreme sports activity
- Poor compliance
Key findings with TAVR in intermediate risk patients
- TAVR was noninferior to surgery with respect to 2 year outcomes of death and stroke
- Transfemoral outcomes were superior to SAVR
- Hemodynamic profile more favorable but paravalvular leak and pacemaker requirement were more common compared to SAVR
- Major bleeding, kidney injury, and AF less common with TAVR
What 2 associated risk were more common in TAVR than SAVR with intermediate risk patients?
Which associated risk were less common with TAVR?
- Paravalvular leak (AR)
- Pacemaker requirement
+ new LBBB
Major bleeding, kidney injury, AF
Name the 2 trials to evaluate TAVR in low surgical risk populations
PARTNER 3 Trial (less incidence AF, shorter hospitalization, lower death, lower stroke) *TAVR now approved in low risk patients
Corevalve Evolut Low-Risk Trial
New LBBB risk TAVR verus SAVR
Higher in TAVR
2 major TAVR valves
Edwards Sapien
Self expanding Core
Mayo clinic conduction management post TAVR
Normal QRS duration
No transient HAVB
PR <240 ms
Next day dismissal without monitoring if no further ECG changes
Mayo clinic conduction management post TAVR
New LBBB + PR <240 ms and QRS <150 ms
Isolated PR ≥240 ms
Isolated RBBB (PR <200 ms and no LAFB or LPFB)
Monitor 24-48 hours, then ambulatory 30 day ECG monitoring if no further ECG changes
Mayo clinic conduction management post TAVR
Transient HAVB
New LBBB + PR ≥240 ms
New LBBB + QRS ≥150 ms with 1st degree AVB or incalculable PR
RBBB + 1st degree AVB
RBBB + LAFB or LPFB
Permanent PM implant
OR
Prolong inpatient monitoring with temporary PM > 48 hours
Mayo clinic conduction management post TAVR
Transient HAVB
New LBBB + PR ≥240 ms
New LBBB + QRS ≥150 ms with 1st degree AVB or incalculable PR
RBBB + 1st degree AVB
RBBB + LAFB or LPFB
Permanent PM implant
OR
Prolong inpatient monitoring with temporary PM > 48 hours
Name some of the populations in which TAVR is still being studied
(ongoing questions)
- Bicuspid AV
- Prosthetic valve degeneration (valve in valve)
- AR
What are some of the limiting factors to TAVR in bicuspid valve?
***RCT have not been done in this population
- Valve may be asymmetrically expanded
- Underexpansion
Risk of PM after TAVR is closely related to
baseline conduction
Every patient with valve prosthesis (even if on warfarin with mechanical valve) should also be on:
*unless contraindication exists or high bleed risk
ASA 75-100 mg/day
Class I
Aortic position, bileaflet/M-H, no risk factors. INR goal?
Everything else, INR goal?
2.5
3.0
Antithrombotics for bioprosthesis
SAVR
TAVR
SAVR
First 3 months: warfarin, INR 2.5
After 3 months: ASA alone (unless other indication for OAC)
TAVR
First 3 months: ASA + Clopidogrel vs warfarin
After 3 months: ASA alone (unless other indication for OAC)
Periprocedural OAC in mechanical prosthesis
- Most patients have only slight risk off OAC for a few days
- Low risk (aortic, bileaflet or tilting disc, no risk factors): No bridging needed
- High risk (everything else): Bridging (UFH in inpatient)
*In order from highest risk to lowest thrombosis risk
Tricuspid > Mitral > Aortic
Ball in cage >Tilting disc > Bileaflet
Other risk: AF, prior thrombosis, hypercoaguability, low EF
Bridging with bioprosthesis
No risk factors: No bridging
Within first 3 months or risk factors: bridge
Plan for pt with low risk prostheses undergoing surgery
*Low risk:
- Aortic position
- Bileaflet or M-H (tilting disc)
- No risk factors (ie no AF, prior embolism, hypercoaguability, normal EF)
- Hold warfarin 5 days *try to continue ASA perioperatively
- Obtain INR morning of procedure
- Restart warfarin immediately
Plan for pt with high risk prosthesis undergoing surgery, bridging required
- Stop warfarin 5 days prior to procedure
- Begin LMWH 3 days pre-op (when INR < 2.0) OR UFH if inpatient
- Check INR on morning of procedure
- Restart warfarin immediately post op
- Remember DVT prophylaxis
- Hold therapeutic heparin for 48 hours post-op
- Continue ASA perioperatively if possible
High-Attenuation Leaflet Thickening (HALT)
- May be as common as 30% in pt’s receiving TAVR or surgical biologic prosthesis
- May represent subclinical leaflet thrombosis
- Annual TTE recommended to monitor gradients followed by TEE or cardiac CTA if abnormal
- If HALT present, warfarin (INR 2-3) recommended indefinitely
When can non-cardiac surgery be performed after TAVR?
Usually 30 days
(sooner if needed)
No bridging needed
Role of balloon aortic valvuloplasty in AS
- Diagnostic tool, BAV can help clarify the cause of sxs
- “bridge to decision” or “bridge to therapy”- ie recent acute decompensated HF, acute renal failure, or decompensated LV function, BAV can be a temporizing therapy to allow for end-organ and cardiac recovery
Occasional role for palliation in the elderly or premorbid patient
*Symptomatic relief for only months, restenosis rates of more than 80% at 1 year
2 main types of stent design in TAVR
- Balloon-expandable
- Self-expanding
Edwards Sapien Valve - balloon expandable valve w/ valve leaflets made of treated bovine pericardium
CoreValve (Medtronic) self-expanding
85-90% of all TAVR valves are implanted by what approach?
transfemoral
*preferred alternative routes: subclavian (usually left), transcarotid, transcaval, transmediastinal
PARTNER IB
PARTNER IA
superiority of TAVR to medical therapy in inoperable patients
Randomized high surgical risk patients to TAVR and SAVR, showed either no difference or improved survival with TAVR
PARTNER 2A
SURTAVI
PARTNER 2A: TAVR to SAVR in symptomatic patients at intermediate surgical risk (Sapien versus SAVR) *not a prospective randomized trial, used historic surgical controls
SURTAVI: TAVR TO SAVR, CoreValve
noninferiority of TAVR to SAVR (endpoint death and stroke at 2 years)
Name some of the main risks associated with TAVR
Stroke
Paravalvular leak
Need for a new permanent pacemaker
Valve thrombosis
Valve leaflet thickening and thrombosis
Durability
*Stroke. Sophisticated imaging with diffusion weighted MRI has made it possible to pick up very small strokes
Development of cerebral protection devices that either capture or deflect emboli during the procedure, mixed results Sentinal
Stroke mitigation in TAVR
Sophisticated imaging with diffusion weighted MRI has made it possible to pick up very small strokes
Development of cerebral protection devices that either capture or deflect emboli during the procedure, mixed results Sentinal
Incidence of paravalvular leak in TAVR
~3-6% incidence of moderate to severe paravalvular leak
~1/3 develop mild paravalvular leak
*Much improved d/t advanced 3D CT imaging to plan, additional valve sizes
Incidence for new, permanent PM in TAVR
~10-30% (most current studies closer to lower range)
- Pt’s with preexisting conduction system abnormalities particularly at risk
Valve leaflet thickening and thrombosis in TAVR
Incidence ~7-10%
Resolution of imaging abnormalities with anticoagulation (indicating valve thrombosis as etiology)
If leaflet thrombosis suspected clinically (increase in mean transvalvular gradient, new or persistent HF, stroke occurring beyond the periprocedural period) CT imaging is warranted
What are some of the key measurements that need to be obtained by CT for TAVR preprocedural planning
Annular size
Height of coronary arteries
Presence of asc aortic and LV outflow tract calcification
Sedation during TAVR
Most now percutaneously through transfemoral access and only local anesthesia with mild-mod sedation needed
General hospital stay after TAVR
~1-2 days in major programs
mitral balloon valvuloplasty indications
Symptomatic MS patients who have at least moderate to severe MS, favorable valve morphology, absence of LA thrombus, and less than moderate to severe MR
*rheumatic MS and calcified nonpliable valves who are at a high risk or unsuitable for surgery
Most common complication of MBV for MS
Severe MR (~2-10%)
MC system used to grade mitral valve when considering MBV for MS
Wilkins
Score of 1-4
leaflet mobility, valve thickening, calcification, subvalvular thickening
Name some causes of primary MR
MVP
Rheumatic disease
Fibromuscular dysplasia
2 classifications of secondary MR
Ischemic
Functional (nonischemic)
Rationale for transcatheter intervention for MR
Mortality rates with surgery 1-5%, additional morbidity rates of 10-20% (stroke, reoperation, renal failure, prolonged ventilation)
Risk much higher the older the patient ~17% in octogenarians
Entry for transcatheter mitral endovascular edge to edge repair
Transseptal approach from right femoral vein
What leaflets are involved in mitral edge to edge repair
P2 and A2
COAPT
Compare mitraclip with GDMT in pt’s with secondary MR
Mitraclip appropriate use
Anatomy must be favorable
Good for use in patients with prohibitive risk for surgery and severe MR
Explain some of the anatomical obstacles to transcatheter mitral valve replacement (TMVR)
Mitral device needs to be larger
Fixation to the diseased mitral apparatus is hampered by the greater valve complexity
Lack of calcium
Potential need for orientation
Noncircular annular shape
*Transapical delivery systems d/t large size of valve needed
TMVR is not a “mitral TAVR”. MV is more complex than the AV, MR has a vast array of etiologies. Unlike AS, MR is not as often a disease of elderly persons and repair (not replacement) is the preferred surgical therapy, especially in primary MR. Replacement may have les favorable effects on normal vortex flow and LV remodeling than a successful repair
*Higher risk of paravalvular leak, greater risk of embolization and LV outflow tract obstruction, and thrombosis
Explain some of the anatomical obstacles to transcatheter mitral valve replacement (TMVR)
Mitral device needs to be larger
Fixation to the diseased mitral apparatus is hampered by the greater valve complexity
Lack of calcium
Potential need for orientation
Noncircular annular shape
*Transapical delivery systems d/t large size of valve needed
TMVR is not a “mitral TAVR”. MV is more complex than the AV, MR has a vast array of etiologies. Unlike AS, MR is not as often a disease of elderly persons and repair (not replacement) is the preferred surgical therapy, especially in primary MR. Replacement may have les favorable effects on normal vortex flow and LV remodeling than a successful repair
*Higher risk of paravalvular leak, greater risk of embolization and LV outflow tract obstruction, and thrombosis
Current guidelines for TR intervention
Concomitant repair or replacement during left sided heart surgery for severe TR and for nonsevere TR with annular dilation
Transcatheter approach to TR
Still in development
