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When TAVI Is Not a Good Indication Didier TCHETCHE, Clinique - - PowerPoint PPT Presentation
When TAVI Is Not a Good Indication Didier TCHETCHE, Clinique - - PowerPoint PPT Presentation
When TAVI Is Not a Good Indication Didier TCHETCHE, Clinique Pasteur, Toulouse. CONFLICTS OF INTEREST RELATED TO THE CONTENT OF THE PRESENTATION Intervenant : Didier TCHTCH, Toulouse Cedex 3 Disclosure: Proctoring/Consulting fees:
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Who is a good TAVI candidate?
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Severe symptomatic aortic stenosis Inoperable patient High surgical risk Heart team assessment Life-expectancy> 1 year
EuroIntervention 2018;14:e380-e382 published online e-edition July 2018 TAVI durability beyond five years: no alarms, but stay alert
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Age: should we treat (very) old patients?
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Add life to years and not years to life
4 hours post TF TAVI
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- Denied patient
- 91 years old
- female
- Comorbidities
- Previous CABG
- LVEF 45%
- Acute pulmonary oedema
- Euroscore 23%
- STS 10 %
- Limited autonomy
- Institution
- Selected patient
- 92 years old
- male
- Comorbidities
- Previous CABG
- LVEF 40 %
- Acute pulmonary oedema
- Euroscore 29%
- STS 11 %
- Generally active
- Living with his wife
Implementation of a geriatrician into the heart team decision
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Age: should we treat young patients?
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Mack et al., Lancet 2015
TAVI durability up to 5 years
CoreValve CE Pivotal Trial
Kovac, Presented at ACC 2014
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0% 20% 40% 60% 80% 100%
2 4 6 8 Time (years)
THV degeneration was defined as at least moderate regurgitation AND/OR mean gradient ≥ 20mmHg, which did not appear within 30 days of the procedure and is not related to endocarditis. KM estimate of THV degeneration included censoring of patients at their date of last known THV functioning well without evidence for degeneration per study definition.
# at risk 378 199 116 43 7
Freedom from THV degeneration
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Valves explanted after 7 years
SAPIEN Platform Durability: testing up to 9 Years
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TAVI Durability Example
PG: 14,6 mm Hg MG: 8 mm Hg Trivial PVL
CoreValve 25 Fr
2015: 10 y Follow up 2005: CoreValve case in Caracas.
Jose Condado, MD.
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Age per se is not a limit for TAVI Lack of autonomy /Severe cognitive dysfunction Life-expectancy< 1 year Young patients: more durability data required
Key Message
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How about the risk profile?
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Impact on the STS score on 2-Year All-Cause Mortality CoreValve ADVANCE Registry
36% 21% 14% 26% 4% 7%
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- R. Makkar et al. JACC 2014;63:901-911
Adverse impact of Risk scores on survival: Sapien experience
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Patients with higher risk scores may not be good candidates for TAVI Logistic EuroSCORE>50 STS score>15
Key Message
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Technical aspects
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Combinaison Flex-Tension guide
Very tortuous anatomy
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Very tortuous anatomy
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A valve-in-valve at high risk of coronary obstruction
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Procedural outcomes depend
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the appropriateness of the access route and the techniques anticipated for TAVI Surgery may be a better option in some High risk patients
Key Message
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Conclusion
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TAVI is not a good indication Patients with (very) short or long life-expectancy Patients with limited autonomy Patients with extremely high risk scores Too challenging anatomical conditions There is no consensus in the Heart Team
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