Chapters Transcript Video TAVR "vs." SAVR? Complementary Modalities for Lifetime Management of Aortic Stenosis Dr. Matthew Summers details a patient-centered approach to valve therapy decisions. One of the things that, that we wanted to start this off uh with the valve therapy session is sort of a description of um how we approach valve disease in general. And uh it's quite difficult to follow a discussion on the aortic valve therapies uh from Doctor Nishimura. But we'll do our best here and we'll try to uh give a framework for how we approach patients with aortic valve disease uh here at Centa. And what a lot of the concepts that he, he brought up during the uh his keynote uh talk, how that translates down to a large volume center like ours. Uh that has very, very, very strong collaboration between our interventional cardiology, uh structural heart doctors and our cardiothoracic surgeons. OK. So we, we currently evaluate more than 1000 patients per year with aortic valve disease. Uh do uh approximately 500 tab or 100 and 50 mile, very, very busy center. Um And when we approach uh valve disease, I I think the title of this talk uh is intentional that um these, these aren't necessarily competing therapies like we thought about even 10 years ago where it was this is a tabor patient or this is a saber patient. These are contemporary, these are complementary therapies that we individualize to each patient. Uh Doctor Kemp brought up in his uh revis session. Uh several cases of younger folks that ended up getting left main PC I and older folks that had uh better rationale for cabbage. And we approach that as the heart team and the heart valve center in a very similar fashion. we're trying to individualize treatments to individual patients based on very specific criteria um and based on our local experience um and goals of care, not just for the initial valve therapy, but for uh the patient's entire life of valve therapy. So our overall goals, if I had to summarize it into um four treatment goals, when we see a patient with severe aortic stenosis is we're trying to expedite treatment. Um This is an elective procedure, tavr or saber um most of the time uh but the disease state itself, uh as we have long known is, is a very uh high fatality disease state and uh a highly morbid disease state. And so it's our goal to expedite treatment um as efficiently as possible, albeit with a significant uh focus on details. We try to minimize the procedural risks in the contents uh context of patient specific risks. We want to provide a durable result and then we want to allow for the safe and feasible reintervention of the valve disease. When uh the first valve wears out. So from a patient perspective, uh what they wanna know uh in, in relation to how we frame this is, will I be ok? Uh until this gets fixed, will this make me feel better? Will I survive the surgery or have problems? How long will this last? And what happens when this valve wears out? Those are the most common questions we get in, in our heart valve clinic. And so, going through each of those individually, what we know and what we've learned over the past several years and sort of how that uh dictates or, or frames how we practice uh aortic valve therapies. Nowadays, this is well well known. It's the, the paper by Doctor Brun Wald, uh showing that the steep drop off in outcomes mortality specifically in patients once they become symptomatic with aortic stenosis, you see on the, the right uh the different curves between asymptomatic and symptomatic. Dr Nura went through several of the, the finer points of, of those things. But in general, we can see that once a patient starts becoming symptomatic and very likely far before then. Um there's a uh progressive process that the, that the clock is ticking, so to speak, and we have to get people through in an efficient manner. So the goal is to triage by risk and expedite that treatment. Um We know from COVID uh when we had increased wait times, uh that there's a mortality decrement with each week that patients wait uh for aortic valve therapies. Um That's been as high as 2% and adjusted risk uh per week after referral. Um And it inde independently impacts their one year mortality, uh their time on that waitlist. So again, we're trying to triage by risk and expedite the treatment. And then we're trying to optimize the procedural risks and those have both patient specific anatomy specific, but also therapy specific uh factors that weigh in. We tend to think about tver, quote unquote versus sar as a the therapy specific risk. But there's very specific patient anatomy uh based characteristics that help guide our decisions on whether a patient would be better served with surgical or percutaneous therapies. When we look at a patient, uh we, we talked about this in the the chip session, the left main session, we have uh some older ways to look at things sts models which have their, their limitations as was described. There are some calculators, uh the AC C calculator for tver specific risk. But really, it, it goes far beyond that, we're estimating the risk of going through that procedure. Yes, but also uh how their comorbidities factor in and what their competing risks may be very commonly referred patients that have terminal illnesses that also have aortic stenosis. And so what, what are the goals of treatment for those patients specifically? What are we trying to accomplish the anatomy specific uh features which was discussed previously, uh whether they're bic cuspid or tricuspid. Um What type of bic cuspid they are? Do they have concomitant aortopathy? How does that impact uh depending on their dimensions where they're at in the disease state and where they may be uh with a potentially not entirely dependent or independent uh uh disease process of having aortic aneurysms. Um Do they have concomitant multi vessel disease or do they have concomitant uh polyval disease, severe mi regurgitation or mi stenosis that would be best served uh with a surgical approach. So, these are all things that we, we commonly factor in and then we look at therapy specific differences after those two. So, um if a patient is better served with cabbage or saber, you know, do they have the rehab potential uh to, to go through cardiac rehab and, and recover from that surgery? Do they have the social support? Um Do they have risks for external complications? And then from our specific therapy with, with transcatheter aortic valve replacement, you know, what are their individualized risks for pacemaker? How does that factor into what the patient prefers or values? Um What are vascular complication rates and, and uh how does stroke potential stroke factor into those? So we, we kind of reserve those therapy specific risks and how we frame these discussions after we look very, very closely at individual patient specific and anatomy specific risks. But the goal again is to individualize uh and minimize these procedural and periprocedural risks for each patient. The other question that was brought up uh is durability. This is an ongoing area of research obviously with the infancy of TVER. Um But we, we do have data as of this from the ESC Congress from a few weeks ago, uh 10 year data for TVER and Saber. And you can see that at least for bioprosthetic valves. Um they have very comparable outcomes through 10 years in a modern uh sort of practice of aortic valve therapy. Uh And that the degeneration rates um depending on how you define things are very similar as well. And so when I talk to patients, we bring this up um should durability factor into our decisions about which valve therapy disposition they ultimately undergo. We're biased, admittedly, structural heart interventional cardiologists by patients age. We see a lot of 90 95 year olds coming in that are still walking miles. They're doing extraordinarily well. They are leading line dances at their a nursing home, a variety of things, but that's not typical. It's still important to realize that the average man in, in the US lives to about 76 years and women live to about 78 to 80 years. Uh And that's changed over time, obviously, but we have to take that into account when we're factoring in how we estimate uh durability in a patient. What the reintervention rate would be. The truth is is that we need to get a specific number of years out of each of these patients. And a lot of it is dependent on their age and their comorbidities. But the truth is that only about 20% of patients outlive their initial A VR. And so there's obviously gonna be improvements with that. With an aging population, there's going to be, uh, a different, uh, patient population mix. Um, we're gonna be applying these therapies to younger patients at lower risk. Uh But right now as it stands about 20% of patients outlive their A VR. And so we have to frame these conversations of selection based on that. Right now. The median time to valve and valve from a savage generation is only eight years. So again, the goal is to individualize the durability assessments based on these uh patient specific factors and not necessarily the therapy itself. And then the last thing is to allow for safe rein intervention. This is uh this, this could be an entire talk by itself, but the higher points or the, the higher points for that. And, and how we discuss individual patients in our valve conference is what is the risk of the next? Valve, is valve and valve tver possible is X plan possible? Are they gonna be a surgical candidate if they have low coronary heights or risk of coronary occlusion, you know, in their mid sixties or mid seventies, what's their surgical risk can be then as opposed to right now. And so all of those things factor into our initial uh discussions and ultimately our recommendations to individual patients about which valve therapy would serve them best. Um The explant risks is an area of uh increasing concern. And that's partly because we, we've been doing TVER, at least at this institution, uh, between three and 500 per year. We, we know a lot more than we did five years ago, uh about things like commissional alignment and the ability to do tab and tab uh anticipating that we'd have future therapies uh to address some of those challenges. Um But we're going to have a, a growing need for uh explant and redo uh stronomy or at least in this case, redo A VR in a lot of folks, the other factors that come into play are coronary access and future revascularization needs. We see patients that have significant ISR recurrent ISR if they have progressive disease with targets, that would be better served with a lema that absolutely factors into things or if we, we know that they're not a, a surgical candidate um with valve specific decisions, we make decisions on valve type based on the ability to treat the corna after the fact. And then as I discussed uh the feasibility of T A and T A uh factors into all of these decisions as well. And so this boils down to sort of kind of th this framework that we, we look at in most patients, which is what is their first valve gonna be? How long are they going to live? How long is that valve gonna last? And then what are they we gonna see for the second valve? And how does that factor into the decisions on our first valve? And so we quite literally map out people's remaining decades of life and each patient when we review them in multidisciplinary valve conference, and we think about these things and we have a collaborative discussion about these things. And because this model includes Sr and TVER and Tav, and Tab and Tab and S A, the whole point is this is that they are complementary modalities to treat the same disease process, which is aortic valve disease, aortic stenosis. When we look at things and on the finer details, we really from a durability standpoint know that if you're 80 plus, you probably need a single valve. If you're 75 you need a good 10 year result. If you're 65 you need a better plan, 15 to 20 year plan. And if you're less than 65 we need more than that. We need, we need a 20 year plan. And so uh to the credit of our surgeons and the way that we, we collaborate on these uh cases, every single one of these cases. Um I wanted to highlight sort of how our process I believe, set sets us apart um and focuses on the patient itself, which is the primary focus that we should all have as health care providers. Um and not necessarily which uh therapy I provide or which therapy Kemp uh provides uh or what sometimes the therapy the patient prefers or wants. And this factors into sort of how we do things here. So this is our approach. We get new patient referrals. They uh come through our heart valve uh center clinic and they're evaluated uh concomitantly by both teams. We arrive at a multidisciplinary valve conference that factors in all of these preparatory um clinical and, and patient specific uh and anatomy specific factors that will help us make that decision. This is an example of someone we did last week, these conferences just so, you know, every Monday at 7 a.m. all the referring are invited, there's a uh teams link that go out. We have lots of people uh collaborate on these calls. Um And you get to see and we hope to shine light on the, the process and how involved it is and how patients uh uh focused it is. But you can see we go through not just the patient's age, not just whether they're gonna get tver or saber. We we factor in their coronary anatomy, their annular anatomy, their iliofemoral anatomy. And then we talk about hemodynamics which Doctor Kemp is going to talk about uh briefly uh in a little bit here. Uh ultimately arriving at a decision that we think is gonna uh best serve that patient, not just for here and now, but also uh for the rest of the remaining uh years with aortic vales. So to summarize our goals uh at this center um where we are managing a lot of patients is to expedite their treatment because we know what the outcomes are. And we do that based on patient specific risks, uh like peak velocity and syncope symptoms, uh reduce TF things that we talked about this morning, we uh have a task of minimizing the procedural risks which have several components, not just therapy specific risks. We want to provide a durable result and we want to allow for safe and feasible reintervention in the future. This is our team, several members of our team and this is after we uh performed, performed the first two geno valves. Um but it highlights the incredible team effort that we have uh in structural heart in our heart valve center. Um There's a lot of people in this audience uh that are, are key members of that team that allow us to take care of patients every day. And I hope this uh sh uh shed some light on how we approach uh valve patients, particularly aortic stenosis patients. Published October 19, 2023 Created by Related Presenters Matthew Summers, M.D. Sentara Cardiology Specialists View full profile
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