New Therapies for Treatment of

Valvular Heart Disease-

Is Open Heart Surgery Still

Necessary

Part 2: Procedures Available and

Options for Candidates

Frank J. Lutrin, MD FACS

Lutheran General Hospital

Cardiac Surgery Associates

No disclosures

In the old days…..

Aortic valve disease was treated with Mechanical Aortic

Valve replacement

Along came tissue valve replacement to offer a

different option

Decisions weighed the longevity advantage of

Mechanical against its disadvantage of need for lifelong

anticoagulation and thromboembolic risks

Options:

Mechanical or tissue AVR

Valve Repair or resuspension

Aortic Root Replacement

Valve sparing aortic root replacement

AVR plus ascending aorta replacement

Any of above in combo with CABG

Transvalvular aortic valve replacement

Options for AVR Tailored specifically

to patient considerations

Patient’s suitability for open operation

Type of aortic valve problem: stenosis versus

incompetence

Isolated AVR may decide mini versus full sternotomy

Associated coronary artery disease

Associated aneurysmal disease

Etiology of the aortic valve disease

Conditions requiring Tailoring the

options

Pathway to determine specific

treatment option

Pathway to determine specific

treatment option

Suitability for open operation: age, previous operations,

overall physical state and comorbidities

Coronary angiogram

Assessment of LV function

Evaluation of Aorta from root to arch

Discussion of valve type: tissue versus mechanical

Pre-operative workup

should be addressed at the time of AVR

May require single or multivessel revascularisation

May eliminate the option of mini sternotomy

Shows relationship of coronaries to annulus

Coronary anatomy

Can help determine risk assessment

Associated pulmonary hypertension and Nitric Oxide

requirement

Planning for inotrope requirement

LV function

Normal Aorta

Hostile Aorta

Aortic root/sinus of valsalva aneurysm

Ascending aortic aneurysm after STJ

Involvement of Aortic Arch

Aortic Concerns

Evaluation of Aorta

Evaluation of Aorta

Evaluation of Aorta

Endocarditis

Leaflet prolapse

Rheumatic Stenosis and regurgitation

Annular dilatation/Aneurysmal distortion of valve

Calcific Aortic Stenosis

Bicuspid or trileaflet

Etiology of Disease Process

Full sternotomy

Mini sternotomy

CABG with LIMA and/or veins

Femoral cannulation or aortic cannulation

Root replacement with Valved conduit

Valve sparing Aortic root replacement

Ascending aorta replacement with or without Arch

Need for circulatory arrest

Planning of operation

General Anesthetic

Sternotomy

Cardiopulmonary bypass

Arresting the heart

Open aorta, remove valve, decalcify annulus, seat prosthesis

Close and restart

Wean off bypass

What does a standard AVR

encompass?

Full sternotomy

Mini sternotomy

General Anesthetic

Sternotomy

Cardiopulmonary bypass

Arresting the heart

Open aorta, remove valve, decalcify annulus, seat prosthesis

Close and restart

Wean off bypass

What does a standard AVR

encompass?

General Anesthetic

Sternotomy

Cardiopulmonary bypass

Arresting the heart

Open aorta, remove valve, decalcify annulus, seat prosthesis

Close and restart

Wean off bypass

What does a standard AVR

encompass?

Composite Valved Graft Aortic Root Replacement

Valve Sparing Root Replacement (normal functioning

Valve)

Aortic Root Aneurysm

Extreme frailty

Advanced age

Previous sternotomy for heart surgery

Previous radiation

Previous mediastinitis

Hostile Aorta

Very poor LV function

Inoperable

Femoral Access

Apical Access

Pre-op stenting if needed

CTA to evaluate Aorta and runoff/Femorals/Iliacs

CTA and Echo to determine annular size

Inoperable or high risk operable

Transcatheter AVR (TAVR)

Long Term Outcomes of AVR in

Octogenerians

515 patients in the Emory Hospital System (1996-2006)

60-69y (206 pts) 70-79y (221 pts) 80-89y (88 pts)

In Hospital Mortality and LOS similar in all groups

Pre op COPD, stroke and RF were predictors of in-hospital mortality

Age significantly impeded long term survival along with smoking, stroke, diabetes and RF

Age on its own not prohibitory : median survival 7.4 years for octogenerians

Placement of AoRtic TranscathertER

Valve Trial (PARTNER)

PARTNER A : looked at surgically inoperable patients

comparing TAVR with standard non-operative therapy

Partner B: looked at surgically high risk patients

comparing TAVR with surgical AVR

PARTNER Mortality

Partner A:

30 day Mortality 3.4% (TAVR) vs 6.5% (AVR)

1 year Mortality 24.2% (TAVR) vs 26.8% (AVR)

Partner B:

30 day Mortality 5.0% (TAVR) vs 2.8% (Std)

1 year Mortality 30.7% (TAVR) vs 50.7% (Std)

TAVR has substantially reduced risk of cardiac death in

inoperable patients with AS

TF TAVR has lower peri-procedural risk than TA TAVR or

Surgical AVR

TF TAVR has higher early Cardiovascular mortality than TA

TAVR or Surgical AVR

PARTNER Neuro events

Early Events within 1 week 4.6% (TAVR) vs 1.4% (AVR

Late 2year data reaches parity

STS Database (1991-2007)

145 911 patients 65 years and older (1026 centers)

Median age 76 years

CLD 16%

Renal Failure 6%

Heart Failure 38%

Reoperation 12%

Median Survivals (STS DB)

60-69yrs 13 years (10 years with CABG)

70-79yrs 9 years ( 8 years with CABG)

>80yrs 6 years ( 6 years with CABG)

If pre-op STS risk >10% Median Survival 2.5-2.7 years

STS Risk factors affecting Median

Survival

CLD 50% reduction

Renal Failure 50% reduction

Heart Failure 25% reduction

Reoperation 25% reduction

Conclusions

Surgical AVR best first option for aortic valve disease

Transfemoral TAVR is a very good option for inoperable

AS patients and for high risk patients with non-CV risks

like renal failure or CLD

TAVR of any access (TA/Tao/TF) has substantial survival

benefit in surgically inoperable AS patients compared

with no intervention

Endovascular Valve Edge-to-Edge Repair

Study II (EVEREST II) Trial

Mortality rates similar at 1 year for Surgical Mitral repair

versus Mitraclip

Mitraclip repair had lower reduction of MR at 1 year

Mitraclip: 20% required Mitral Surgery at 1 year

Mitral Repair: 2.2% required Mitral Surgery at 1 year

Mitraclip: 25% required Mitral Surgery at 4 years

Mitral Repair: 5.5% required Surgery at 4 years