Κωνσταντίνος Τούτουζας. Αναπληρωτής Καθηγητής Καρδιολογίας Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Νοσοκομείο Αθηνών

Κωνσταντίνος Τούτουζας Αναπληρωτής Καθηγητής Καρδιολογίας Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Νοσοκομείο Αθηνών

Dr Paul Dudley White 1931

Homograft 1962 First PVT animal implantation A. Cribier First Corevalve animal implantation JC. Laborde Mechanical heart valve 1962 Transvascular Porcine valve 1965 Pericardial tissue valve 1969 First Edwards/PVT Transapical Beating Heart AVR Webb, Lichtenstein Nov 29, 2005 Hippokration Hospital, 1 st CoreValve implanted 1960 1970 2000 2001 2002 2004 2006 2008 2014 Surgery First PVT Transcatheter AVR by Antegrade Approach Alain Cribier - 2002 First CoreValve Transcatheter AVR by Retrograde Approach Laborde, Lal, Grube July 12, 2004 >100.000 TAVI Valves implanted worldwide First CoreValve PERCUTANEOUS AVR by Retrograde Approach Oct 12, 2006 Serruys, DeJaegere, Laborde

(X 1000) 60 50 40 30 20 10 0 0.7 CAG: EU 14% US 27% 14 2 19 5 24 US 11 27 16 2010 2011 2012 2013 2014 2015 2016 2017 2018 31 EU 20 35 27 40 ~90K procedures by 2018 32 47 37 52 Multiple Industry Sources - 2013

Existing TAVI Devices TAVI Studies Future TAVI Devices

K. Toutouzas, K. Stathogiannis, G. Latsios, A. Synetos, C. Stefanadis, 2012, Recent Pat Cardiovasc Drug Discov

TCT 2014 S. Yakubov

Genereux et al., JACC, 2012 Urena et al., Circulation, 2014

235 ασθενείς (213 μέσω Μηριαίας; 22 μέσω Υποκλειδίου) Επιτυχής τοποθέτηση σε όλους Μέσο Κ.Ε. 58±3% Μέση Κλίση Πίεσης 8mmHg Μέση Νοσηλεία 5±1 ημέρες FU έως 28 μήνες Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών 2014

Nishimura et al, 2014

Stroke Bleeding Vascular complications Device positioning PVL

Medtronic CoreValve Evolut R Edwards Sapien 3 and Centera Direct Flow Medical BSC Lotus Symetis Acurate Valve Medical

CoreValve Evolut R Tailored height and fit Optimized radial force Coaptation in non-circular anatomy Anti-mineralization treatment: Reduces early and late valvular calcification Toutouzas K et al, HJC Supplement, 2014

CoreValve Evolut R Longer landing zone for better sealing Toutouzas K et al, HJC Supplement, 2014

CoreValve Evolut R

CoreValve Evolut R Low profile Recapturable Repositionable Advanced valve performance CoreValve Evolut R CE Study (n= 60) CoreValve Evolut R US Study (n= 250)

Sapien 3 Reduces further PVL Delivered through 14 Fr esheath Bovine pericardial tissue

Sapien 3 V. Thourani, TCT 2014

Self expanding Centera

Direct Flow Non-metallic frame Bovine pericardial tissue 18 Fr delivery and retrieval for all sizes Treatment range: 19-26 mm

Direct Flow C. Davidson

Direct Flow

Direct Flow C. Davidson

Lotus I. Meredith

Acurate H. Mollmann

Acurate

Valve Medical

TAVI proved its safety and efficacy in the mid-term Long-term results (>5 years) are eagerly awaited The newer generation valves show a great promise in safety and applicability The trend of TAVI towards intermediate-risk patients is the next big thing

Valve Medical

Kappetein et al., EHJ, 2012

Intermediate-risk Patients 405 TAVI 405 SAVR Piazza et al, JACC, 2013

Intermediate-risk Patients Wenaweser et al, EHJ, 2013

Intermediate-risk Patients Piazza et al, JACC CV Interv, 2013

Intermediate-risk Patients Osnabrugge et al, Ann of Thor Surg, 2012

Intermediate-risk Patients

Intermediate-risk Patients Low procedural risk Optimal valve performance Optimal valve durability Experience with TAVI

Roberts et al, AJC, 2012

Dilated aortic root Big angulation 2 pig-tails used Roy et al, JACC, 2013

Seiffert et al, JACC Card Interv, 2013

100 year old male patient, mobile Severe symptomatic (NYHA III-IV) aortic valve stenosis Med Hx: hypertension on amloride/furosemide Echocardiography: EF 30%, estimated pulmonary pressure 50 mmhg aortic valve area 0.5 cm2, mean gradient 45 mmhg, peak gradient 105 mmhg No significant coronary artery disease

EuroScore 41% Katz ADLS 6/6 Groningen Frailty Indicator 1/15 Fried Frailty Index 1/5 passed : eye ball test grip strength test and gait speed test Karnofsky index 80-90

Pre-procedural Karnofsky index (functional performance status) as the only independent predictor of TAVI outcome. Eur Heart J. 2010 Apr;31(8):984-91.

29 mm CoreValve TAVI (trans-femoral 18 F access)

29 mm CoreValve implantation under light sedation/ local anesthesia End result 5 mmhg gradient no Aortic Regurgitation

Stable and mobile Improvement in dyspnea (NYHA I) Echocardiography: Aortic valve area 1.8 cm 2 with trivial paravalvular regurgitation mean gradient 9 mmhg, peak gradient 18 mmhg, EF 30%. 2 year follow up Same clinical and echo condition Walks, writes memoirs (!) 102 years old 5 meter gait speed test

Special Contributors: G. Latsios A. Synetos K. Toutouzas

SURGERY TF-TAVI Genereux et al, 2013, JACC

By SamirKapadia

Δεν υπήρχε διαφορά μεταξύ των δύο ομάδων Thourani VH ACC 2013

Kodali et al., NEJM, 2012

TAVR Patients had Lower Mortality N= 795 Adams DH et al. N Engl J Med 2014

Procedural Outcomes N= 795 Adams DH et al. N Engl J Med 2014

In patients with prohibited risk for SAVR, TAVI showed an one year all-causemortality of 26%, much lower than the optimal performance goal (43%) Popma J, et.al., JACC 2014

89% Η επιβίωση των ασθενών που υποβλήθηκαν σε διαδερμική αντικατάσταση αορτικής βαλβίδας (Core Valve) στην κλινική μας ανήλθε στο 89% στα 3,5 έτη παρακολούθησης. Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών 2014

2,47% NYHA after TAVI 1,24% 30,86% 65,43% NYHA I NYHA II NYHA III NYHA IV Η TAVI είχε ως αποτέλεσμα σημαντική βελτίωση στη λειτουργική ικανότητα κατά NYHA στο 1 έτος παρακολούθησης. Α Καρδιολογική Κλινική Πανεπιστημίου Αθηνών 2014