TAVI: Asian Perspective

NUHSNational University Health System

NUHSNational University Health System

Aortic stenosis in Singapore

Tay et al. SMJ 2012 (In press)

Mean logistic euroscore: 10.7+/-12.3

Refusal rate for open heart surgery 42.2%

Tay et al. SMJ 2012 (In press)

Unique challenges in Asian cohorts

Smaller annulus sizes Smaller femoral sizes Smaller LV cavity size More frail?

Aortic root dimensions

Total(n=249)

Degenerative (n=216)

Rheumatic (n=11) Bicuspid (n=22) P value

Aortic dimensions

Annulus 20.3±2.0 20.2±1.9 20.7±1.3 21.2±2.5 0.045

Sinus 32.3±5.0 32.3±5.0 30.5±1.4 33.1±4.8 0.67

STJ 26.6±5.2 26.5±5.4 24.7±2.1 27.9±3.6 0.50

Ascending Ao 33.9±5.9 33.6±6.0 30.2±4.2 36.4±4.6 0.11

Upper Ascending Ao 35.3±6.0 35.4±6.2 33.1±3.0 35.3±6.0 0.88

Tay et al . SMJ 2012 (In press)

Int J Cardiol 2012 (In press)Int J Cardiol 2012 (In press)

MalesMales FemalesFemales

Unique challenges in Asian cohorts

Smaller femoral sizes

Patient AgeEthic group

GenderSTS score

EF eGFR Co-morbidities

1 72 Malay Female 2.4 25 47 Cardiac cachexia

2 93 Eurasian Male 14 70 18 Chronic obstructive lung disease.

3 80 Chinese Male 3.1 50 60Co-existent severe mitral regurgitation and low

boy weight (BSA1.4)

4 82 Malay Male 4.2 33 38 Limited mobility from bilateral OA knee

5 86 Indian Male 5.2 70 40 Limited mobility from bilateral OA knee

6 61 Chinese Male 7.3 35 10 Previous CABG with patent saphenous vein grafts

7 84 Chinese Female 8.8 45 51Previous Ca breast with radiation. Low body

weight

8 84 Chinese Male 4.7 65 47 Limited mobility

9 88 Chinese Male 3.0 70 60 Concomittant thoracic aneurysm requiring TEVAR

10 78 Chinese Female 4 75 54 BSA 1.4 (small size). Cardiac cachexia

11 92 Chinese Female 12.4 69 50

12 82 Indian Male 11.8 70 41 On chronic immune suppression

13 73 Chinese Male 6.3 30 60 Previous CABG with patent saphenous vein grafts

14 79 Chinese Female 7.7 60 47 Limited mobility and obesity

Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

PatientAnnulus

(mm)

Femoral artery size

(mm)

Access Site

Valve size

Length of stay (days)

PVL MR30 day

mortality

1 19 4.1 TA 23 15 Trivial Moderate►Mild-mod Nil

2 24 4.4 TA 26 52 Mild Mild (unchanged) Nil

3 21 7.4 TF 23 10 Trivial Severe►mod severe Nil

4 24 6.4 TF 26 70* Mild Mild to mod►mild Nil

5 21 7.2 TF 23 6 Mild-Mod Mild (unchanged) Nil

6 23 5.2 TA 26 9 Mild Mild (unchanged) Nil

7 20 5.6 TA 23 8 None Mild (unchanged) Yes

8 20 8.3 TF 23 6 Mild Mild-mod►mild Nil

9 24 7.8 TF 26 17 Mild-Mod Mild (unchanged) Nil

10 23 4.8 TA 26 12 None Mild (unchanged) Nil

11 21 6.2 TF 23 10 Mild Mild►mild-mod Nil

12 21 6.3 TF 23 17 Mild Trivial (unchanged) Nil

13 24 6.2 TA 26 7 Trivial Mild to mod►mild Nil

14 21 6.5 TF 23 33* Mild Mild (unchanged) Nil

Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

Baseline 30 days

IV

III

II

I

0

10

20

30

40

50

60

70

80

baseline Immediate post 1 month 3 month 6 month 1 year

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Improved functional class

Reduction in mean gradient

Tay and Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

Tay and Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)

Patient selection

Patients are determined to be high risk by two cardiac surgeons

Reviewed by TAVI team Decision on TAVI and access

TAVI workup

Traditional• Coronary angiogram and right heart

catheterization+/- PCI• Transthoracic and Transesophageal

echocardiogram• CT coronary angiogram+aortogram

(including ileofemorals)• US carotids, PFT, usual pre-op labs• Determine angles of implant on the on day

of procedure

Currently:• Using CT to plan implant angles (if CT

available)• Using DynaCT if implant angles not

available• Using DynaCT and overlays if aortic

aneurysms present

Challenges (1)

With diagnostic CT• Pre-procedural CT with difficult

imaging in tachycardic patients/those who are in failure/AF

• Renal failure patients an contrast concerns (differences in Asian cohorts)

Challenges (2)

DynaCT• Need for rapid pacing and significant

volumes of contrasts• ‘static’ overlays

The ideal situation

Pre-procedure:Minimize pre-procedural scanning/testing eg (1 test provide annulus size, ileofemoral sizes, angle of implant, coronary arteries, calcium volume)• Powerful pre-processing software

Less contrast/less pacing ‘Dynamic/Live’ overlays

• Safe and effective procedural imaging

EducationEducation ResearcResearchh

Clinical

Clinical

First in Asia series published Maintain the highest quality of care

for valvular heart disease patients Standards and outcomes audited

according to international TAVI benchmarks

Education

Providing training for transcatheter aortic valve implantation in Singapore

Providing training to new operators and regional centres in TAVI

Incorporating TAVI and hybrid OT technologies in imaging/interventional meetings

Fellowship and residency programmes

Research

Diagnostic imaging (CT for sizing in access sites Asian patients)

Novel biomarker research into aortic stenosis and TAVI

Clinical trials and test site for second generation TAVI valves

Asian database for valvular heart disease

Thank you