Transcript Slide 1

Standard Aortic Valve Replacement vs Transcatheter Aortic Valve Replacement
By: Victoria Adams and Paul Cho
What is it?
What is it?
PICO Question
The standard approach for an aortic valve replacement involves a
surgical procedure to replace the patient’s diseased aortic valve
with either a mechanical or bioprosthetic valve. This procedure
is usually done through a sternotomy (open heart).
In patients over the age of 65 with symptomatic aortic stenosis, will
standard aortic valve replacement or transcatheter aortic valve replacement
have a lower mortality rate after 1 year?
What is Aortic Stenosis?
Aortic stenosis is the narrowing of the aortic valve due to calcifications of its
leaflets. It‘s incidence usually increases with age. If left untreated, aortic
stenosis can cause symptoms such as syncope, chest pain and dyspnea. All
which can greatly increase the rate of mortality.
Who gets it?
It is recommended for almost all patients that are symptomatic
from their aortic stenosis. There are a few patients that are not
eligible for this procedure. The surgery cannot be done if there
are more pressing medical conditions or if the patient will not
likely survive surgery. If the patient is hemodynamically unstable
and cannot go through the open heart surgery immediately, an
aortic balloon valvotomy can be performed until the valve can
ultimately be replaced.
Procedure
-A 6-8 inch incision is made down the sternum.
-The heart is connected to a bypass circuit and the heart put into
a hypothermic state for protection.
-The aorta is cut and the aortic valve is exposed.
-The diseased valve is removed and a prosthetic valve is sewn in.
-The aorta is closed, cardiac function resumed, the patient is
weaned off the bypass circuit, and the sternum is sewn back
together with wires.
References
-Bonow, R. O., Mann, D. M., Zipes, D. P., & Libby, P. (2012). Management of valvular
heart disease. InBraunwald's Heart Disease - A Textbook of Cardiovascular
Medicine (9th ed., p. 1468). Philadelphia, PA: Elsevier Saunders. Retrieved from
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-0398-6.00066-4-sc0015&isbn=978-1-4377-0398-6&sid=1381627464&uniqId=382572064-6
-Shabir, D. B. (2011, January 26). Medelineplus. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/007408.htm
-Smith, R. (2012, 01 25). Aortic valve replacement - recovery. Retrieved from
http://www.nhs.uk/Conditions/Aorticvalvereplacement/Pages/Recovery.aspx
-Townsend Jr., C. M., Beauchamp, R. D., Evers, B. M., & Mattox, K. L. (2012). Sabiston
textbook of surgery. (19 ed., p. 1671). Philadelphia, PA: Elsevier Saunders. Retrieved
from http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-15606.C2009-0-60514-6&isbn=978-1-4377-1560-6&uniqId=382572064-10
Placement of AoRtic TraNscathetER Valves
Comparison of TAVR/THV vs. Standard AVR
Outcome At 30 Days
Standard
Transcatheter
All-Cause Mortality
6.50%
3.40%
All Stroke or TIA
2.40%
5.50%
Major Stroke
2.10%
3.80%
Major Vascular
Complications
3.20%
11.00%
Major Bleeding
19.50%
9.30%
New Atrial Fibrillation
16.00%
8.60%
New Pacemaker
3.60%
3.80%
Outcome At 1 Year
All-Cause Mortality
All Stroke or TIA
Major Stroke
Major Vascular
Complications
Major Bleeding
New Atrial Fibrillation
New Pacemaker
Standard
26.80%
4.30%
2.40%
Transcatheter
24.20%
8.30%
5.10%
3.50%
25.70%
17.10%
5.00%
11.30%
14.70%
12.10%
5.70%
Conclusion
This study shoes that TAVR is superior in all-cause mortality rates than
standard AVR. Conventional standard AVR is being challenged by TAVR which
is showing an advantage in areas such as recovery time, lower bleeding
complications, new atrial fibrillation onset and availability to pateitns who can
not undergo invasive surgery. Still, standard AVR shows a better outcome for
incidences of stroke. As TAVR advances and becomes more refined, it
certainly has the potential to replace the need for invasive open heart surgery
in replacing stenotic aortic valves.
TAVR is a procedure used to treat symptomatic aortic stenosis.
An artificial collapsed aortic valve is guided through a large
vessel(usually the femoral artery) in a retrograde fashion to the
aortic valve. The valve is meticulously placed into position and
expanded to push aside and replace the stenotic aortic valve.
The Sapien catheter heart valve was approved in November of
2011.
Who gets it?
TAVR is used to treat symptomatic aortic stenosis in patients
where the risk of surgery are unacceptably high
AND. The decision is made by an experienced cardiothoracic
surgeon, a multidisciplinary valve team and by risk stratification
using the Society of Thoracic Surgens (STS) model. There are
also certain criteria that must be met including:
-Calcific aortic valve stenosis with the following present on
echocardiogram:
-Severly calcified vavle leaflets with reduced motion
-An aortic valve area (AVA) of less than 1cm2 or indexed
effected oriface of less than 0.5cm2/m2
Procedure
-A collapsed artificial valve is introduced through a large vessel,
most commonly the femoral artery, and it is progressed
retrograde until it reaches the aortic valve.
-Through guidance of a transesophageal echo and fluoroscopy,
the collapsed valve is placed into the stenotic aortic valve and
expanded to replace it.
References
-Gaasch, W., Brecker, S., & Aldea, G. (2012). Transcatheter aortic valve replacement.
Retrieved from http://www.uptodate.com/contents/transcatheter-aortic-valvereplacement?source=search_result&search=tavr&selectedTitle=1~18
-Nielsen, H., Klaaborg, K., Nissen, H., Terp, K., Mortensen, P., Kjeldsen, B., Jakobsen, C.,
& Andersen, H. (2012). A prospective, randomised trial of transapical transcatheter
aortic valve implantation vs. surgical aortic valve replacement in operable elderly
patients with aortic stenosis: The staccato trial.8(3), 383-389. Retrieved
fromhttp://www.ncbi.nlm.nih.gov/pubmed/22581299
-Singh, I., Shishehbor, M., Christofferson, R., Tuzcu, E., & Kapadia, S. (2008).
Percutaneous treatment of aortic valve stenosis. Cleveland Clinic Lournal of
Medicine, 17(11), 805-812. Retrieved
fromhttp://www.mdconsult.com/das/citation/body/3724531614/jorg=journal&source=MI&sp=21597527&sid=1367151656/N/21597527/1.html?issn=
0891-1150