Chapters Transcript Video TAVR: Past, Present, Future: What All Clinicians Should Know Dr. Deepak Talreja reviews the TAVR team concept and presents ACC/AHA guidelines and evaluation pathways. All right. Thank you for the opportunity to talk today. You've heard two great talks on TVER and prior to that, a keynote address addressing a lot of this as well, that'll help each of us. We have a little bit of overlap as we go through our slides. One thing I wanted to do is quickly look back at the last decade. It's amazing when you think about where we are and where we've come from. I started here in 2004 and it was an amazing revolution in around 2010 when we started our first formal uh structural heart valve center here. Um That team consists of currently three cardiologists. We have two more coming on board. In the next year. We anticipate um up to nine cardiovascular surgeons and some have come and gone as we've gone through, but they've been tremendous partners, Subspecialty A PPS team, Navigator, outpatient teams, Cath lab teams, surgical teams, noninvasive colleagues. It really does take a village to take care of these patients. Our first Tavern implant was back in 2011. And as Matt alluded to, you know, in that era where we were taking care of inoperable patients. We had proctors from overseas coming and doing our cases, patients were uniformly intubated. Um We had, um, cut down access with vascular surgery teams for every one of those patients we could do maybe one or two in a day. The goal really was to get successfully off the table. We did transfemoral approaches and transapical approaches and the transapical were frankly brutal and it's now been years since we've done one of those. Now, a little over a decade later, we've done over 3700 catheter valve implants at this facility. We have an education center. We do training with each of the major vendors in the area and we've been involved in some of the pivotal trials that have shaped this field in each of the major platforms and those are ongoing. Now, many of you have participated as we've had folks come and train in our learning center, uh come see us in the or and hear case education as we go. Our current access routes include transfemoral, which is favored uh trans April. We haven't done that in a while. Trans carotid, trans secan direct aortic trans cable and approaches like basilica. And those are all complex terms. You'll hear some of these as you see notes coming back and forth and at different talks in some of the grand rounds, we've gone through some of these procedures, but it is really remarkable where the fields gone and it's all driven by team based care. One thing we're very careful about Matt alluded to this and I really have to give a lot of credit to the whole team, but also to Matt and to Clint this year, we did a very intentional redesign of the whole intake and follow up process. And the two of them led that in a really organized and methodical way. But when we look at this, it takes everyone taking care of these patients from the first person that sees them in clinic to the cardiac rehab, taking care of them for the weeks and months after the procedure. These are a couple pictures of our team. It's a huge team. There's no way to get everyone no matter how many photos I've gone through. Uh But this is uh this is on the left us in the heart hospital, on the right us celebrating one night. Uh And then on the bottom matt showed that picture as well. There are a lot more, but you get the point. Uh There's so many of us involved. Candice will make sure you're in the next one. All right, if you look at what's going on, it's interesting across this space. There's a ton of different things happening. You'll hear about the micro and Tricuspid space. Next. This is not enough time to really go through it. I'll focus on the air space and we've already heard the slight debunking of this curve from Doctor Nishimura I'll keep moving through it. We've seen again what these valves look like. It's amazing when you think back to the idea of doing this came out in the 19 seventies, 19 eighties. But it took until 2002 for the first human transcatheter valve implant to occur. And then 2011, when we started, there are a number of different platforms available. Some have even come and gone in the time that we've, uh we've been around now and these are some of the uh the ones currently available. You've seen some discussions on this already from both Clint and Matt. And as you look, you've heard, we've been involved in many of these pivotal trials from initially the extreme risk almost inoperable patients now to low risk and bicuspid. Some of the new trials that are going on that we could talk about. We're in the next generation of the SAPIEN platform. We're optimizing use in trial of our core valve platforms. We're in the largest generation of the navato valves. We're looking at treating asymptomatic severe A S patients in trials to figure, can we prove that that group can benefit and we can move them from a consideration to an absolute group we treat. So the rest of what I'm gonna talk about is what's I think in, in five minutes useful for the referring provider and for folks that run into patients that are having t to just know about what, what we do to evaluate these patients and what needs to be a consideration afterwards. So, these are the three commercially approved valves that are most commonly used by us. There are other valves we're using in trials. Matt alluded to the Yena valve. Um, there's uh the accurate ID valve. We were in uh the lotus trial. So a lot of different valves available, but these three are our mainstays. Uh some patients actually have opinions as to what animal tissue they kind of want in them. Most don't really care once we talk about it. But this lays out there's metallic frames with tissue components inside last year. One of our, yeah, last last year, one of our keynote addresses was on some works that are being done to look at artificial tissue in these valves and that's still in its very early stages. But all these valves work really well and we individualized to each patient based on risks. Like you've heard this has been the evolution with the Edwards platform. We started with that first valve, the original SAPIEN Edward SAPIEN Valve. And now we're in the third generation and in trials with the fourth generation of this valve. This is the same thing with the Metronic platforms where again, we started with the original valves in the first series of trials and now have evolved into the evolut FX trial or F FX valve, which is what we routinely use. And that allows commissure alignment. These valves now have skirts on them. It's been amazing to see the evolution. The original sheets were double the size of what we're using now. And that that reduction in sheath size has made this a lot safer in frailer, sicker and older patients. Again, the movement has been from the highest risk patients now to the lowest risk patients. And it's widened out technology and our ability to take care of patients. One important point I do want to make though. And I think everyone's alluded to this is when patients come in to see us. Many have a preconceived opinion that they, for example, want tor that, that's a complicated decision and we try never to leave them with the impression that that that's a casual decision that should be made. Every patient is evaluated for both transcatheter and surgical techniques. And really until we know what their CTS show what their multidisciplinary work up has shown, we don't know what's the right therapy and we'll obviously take their preferences into account, but it's our job to guide them to what's the best therapy for them. And it's changed right back in 2011 mortality stroke, some quality of life and pacemaker and paravalvular leak were our main concerns getting the patient off of the table alive. And many of those patients had such high non valve related risks that many had very short life expectancies. So success was largely driven by the procedure itself. And the immediate term outcomes. Now, the world has changed. Now, it's about lifetime management metrics. It's not enough just to get them off the table. We have to make sure that valve is durable. As you've heard. Very nicely already. We have to think about their life expectancy, the valve life expectancy and the next plans. This is the uh the latest generation of the AC C guidelines that has already been covered. So I'll keep moving through. I thought it would be helpful when I'm in the room with a patient educating about TVER. I always pull up. Usually it's easiest on youtube and you can Google any of these very quickly or youtube. I show them what the procedure kind of looks like from an A cartoon standpoint. So I'll show you two of these and I'll move through fairly quickly. But honestly, with each patient, I sit in the room and show them and for those of you that haven't seen this, I'm just gonna take AAA total of three minutes of my time and uh and show you the videos that I do like to pull up in the room. So once we've obtained our large chief access, the latest generation of the editor system has a balloon that's pulled back within the valve frame. The valve is crimped down by our teams on the back table while we're getting access and then we pull the balloon into the frame. That's a metallic frame of Cobalt chromium with the tissue mounted inside it and then under fluoroscopy and sometimes using some echo parameters for guidance as well. We advance the valve around the aortic arch and position it down in the aortic valve that you can see there. I think it helps patients to understand what's going on and it alleviates fear a lot of times if they can understand a little bit about what we're doing and helps them be patient with us as we go through the process and understand why we need the an atomic mapping that we need. So we align the valve within the old valve. We use different markers and injections of contrast dye to make sure we're really in the right spot. And then one of the brilliant uh solutions to being able to safely put the valve in is we rapidly pace the patient at something like 100 80 beats per minute. And you'll see that on this animation right before we inflate the balloon to deploy it. And what that does is it prevents the heart from trying to push blood through and eject the valve. And so we rapidly pace, deploy the valve and then we can analyze that. That's with the SAPIEN system. I'm gonna move on and show you a similar animation with the Metronic system. And the Navato system is very similar in, in its sense that these the Metronic one and the Navato one with Abbot are both self expanding valves. So they work in a slightly different way. And this animation shows again, we're looking at a fairly normal aortic valve which is going to age it right before us into a sonic valve. And then we'll look at our access and again, there are multiple access points we can go through, we typically like transfemoral routes if the arteries are big enough to accommodate this, but we can go across clavis carotids or even puncturing through a vein and then going into the aorta through the side wall of the vein. With this system, it's a self expanding stent. We position it, it's recapture, we can partly deploy it, recapture it, deploy it, recapture it until we find the right position. And that's what you just saw there is that was too low. So we reposition again, potentially rapid pacing, put it in place and immediately you have a functional valve from an operator standpoint. It's really exciting to see kind of an instantaneous result where you can see the gradient go down from very severe 50 millimeter gradient down to just a few millimeters of mercury. And that's what we're looking for is single digit gradients with each of these procedures. As we've gotten more advanced with each of the platforms, we've been lucky to participate in some of the trials that have helped develop techniques with the second platform I showed you there's now ways to look at where the cusps will lie. So we can make sure we don't overlap coronary arteries and these iterations have been brilliant moves that, you know, engineering teams have really thought through and we've been lucky to participate in testing those. So the other thing that's really complicated is the scoring and matt alluded to this a little bit and, and Clint did as well. Um It's complicated there, there's very um basic scoring systems, but a lot of it comes down to judging the patient and thinking about what's going on. Both these patients have an sts risk score of two, which would put them in the low risk range. On the left is patient a who's 74 no previous surgeries. Otherwise healthy, primary caretaker for a husband with dementia, that's something that matters because it means a shorter recovery would be useful and their an atomic imaging shows good femoral access and no other significant abnormalities that patient would do well with either procedure likely given age and everything else. We would think about a tavern. That patient, the next patient is 59. Also sts risk score of two. A diabetic elevated creatinine cuspid valve with a calcified RAA, a lot of calcium that might unpredictably move and shift on us. And they also have an aortic aneurysm. That's a patient that really should go to surgery despite the same identical sts risk because they need an aortic repair. Now, many times that's the patient that comes to us and said, I heard you guys are doing Tavis. That's what I want. But it's our job to educate them, work up and figure this all out together. And in the same way, sts risk score doesn't really do a great job of accounting for frailty. Doctor Nishimura was mentioning Grip strength. That is a really great surrogate of a lot of the functionality of a patient. Both of these patients have the same sts risk score, but from an eyeball test, they look very different. The one on the top is a much frailer patient. He would anticipate a slower recovery in um what makes savor a better choice for some of these patients, hostile aortic root complexes, low coronary heights. Although again, we've come up with some neat solutions to some of these problems, uh narrow sinuses, if they have a root that really should be enlarged to allow a larger valve to come into place. Lack of transfer access, concomitant surgical disease matt called this out already and then patient age and durability considerations. We talked about the fact that we're not just planning one valve. When we see these patients, we're planning the next series of interventions in that valve space and what other valves, what other vessels, what other problems might come up that need therapy so quickly in the last couple of minutes when we screen these patients, when they get referred in, we typically get a gated CT A TVER protocol CT A that can be done pretty much at any of our facilities. There's extensive analysis and our A PPS are really amazing. They can do 3D manipulations and get incredible measurements of this. And our industry partners do the same thing. So we get two sets of measurements for every patient. We will often do a right and left heart cath. There are some situations in which we may not if we think the risk and benefit are not favorable for that. And we get enough information from CT A. We routinely get Panorex scans or get in touch with their dentists and get a recent Panorex within the last month or so. In days past, we used to also get um carotid evaluations and PFTs. Those are largely driven by patient needs and are not routine tests anymore. We do functional assessments, sts risk score cal calculations and then as Matt and, and Clint pointed out, we have a multidisciplinary team evaluation. Once all that data comes out, we do extensive multimodality imaging. So we know exactly where we're getting into right plan every detail. So we know what we do in, in place of any issues if the patient has to have an operation in, in the middle of the procedure. Um we know what size valve they need, what are the, what are the complexities of that and so forth. And Matt's already shown the same thing. Every patient gets this full team work up, which is pretty amazing. The other thing that's been neat. To see is the economics of this in, in health care. We know, uh, I'm, I'm gonna ask, I'll ask the question before I say it. I just recently saw, published out latest C MS data for every $1 for every 100 cents spent in medicine. Think for a second. And guess how much of that goes to ultimately cardiology care? I mean, you think about it? We got plastic surgery, orthopedic surgery, general medicine, endocrinology, rheumatology. I a million specialties. How much is spent on cardiology? 90. Wow. Oh my gosh. I like that. Uh, you guys were primed for this. So my answer is not gonna be as impressive as it was when I saw it was 43 cents of the dollar is spent on cardiology. When you think of all the disciplines out there. That's a lot. What's neat about TVER is this is a curve that shows cost effectiveness and quality on the right side is increased survival compared to the standard of care, which was a surgical A VR on the up, downside up means it costs more down on the Y axis means it saves money. The ideal quadrant C MS long ago decided $50,000 per quality of the year of life saved is a reasonable trade off at the end of the day in this. What we see is we see that TVER saves about $10,000 with an increase in 0.5 quality years of life. Saved. That's an incredible win. And you don't always see that in medicine where we've got new technology that's both ultimately less expensive and improves quality of life. So you let me go through a lot of stuff at once. Thank you all for coming and attending this and uh thanks for all the help. Oh, and lastly, post op care SB prophylaxis and anticoagulation. Uh We, we guide in our procedures. Published October 19, 2023 Created by Related Presenters Deepak Talreja, M.D. Sentara Cardiology Specialists View full profile
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