Melissa Walton-Shirley


March 31, 2014

If you had asked me as I stood at the doorway of today's presentation on valvular heart disease, "Which would you have at age 80 if given the choice, a surgical aortic-valve replacement [SAVR] or a transaortic approach [TAVR]?" I would have replied, "Well, that's easy. I will do anything—well almost anything—to avoid a median sternotomy."

I admit I was biased. My father had a TAVR two years ago. None of the family could stand the thoughts of "his" reliving (or perhaps selfishly, "our" reliving) the three-month ventilator stay his chronic obstructive pulmonary disease (COPD) bought for him at the time of his CABG in 2000. Add to that a nine-month mind-boggling rehab stint. An open-chest procedure was simply a no-go. But following the presentation this morning, if you asked me again about my own choice of TAVR vs SAVR, my answer will now be far more thoughtful. Perhaps I might just need to go ahead, put on my big-girl compression stockings, purchase a big ole bottle of hydrocodone with some Benefiber, and have that median sternotomy. Conversely, if you'd ask me if a bicuspid aortic-valve patient could have a successful TAVR, I would have said, "Probably not such a good idea."

The presenters today made it clear there are many considerations before we pull the trigger on the TAVR or the SAVR approach to aortic-valve disease. Changes in technique, length of stay, cost concerns, and complication rates are as quickly changing as a stock-market tickertape. I should not have judged so quickly on any point.

The first presenter was Dr Darren Mylotte from Galway, Ireland, by way of Montreal, QC. I saw him many years ago when he presented the first oral presentation on the topic of trans-aortic-valve implant I'd seen at a formal meeting. He's left us behind now as I'd expected, having moved on to bicuspid aortic valves. It's something we've all wondered about for quite some time. He reported on an impressive 143 procedures today.

The presenter clicked through the varying bicuspid morphologies, and in this group, most were the single raphe type I. He emphasized the troublesome calcification that extends both across and within leaflets, as compared with the tricuspid aortic-valve distribution at the sinus of Valsalva and the leaflet base. He navigated us through the obstacle course of asymmetric leaflet closure, a frequently highly angulated annulus, the dilated aortic-root issue, and the ever-present concomitant aortic insufficiency.

The cohorts were aged 77 on average with the obligatory lopsided male enrollment of 82%. Of the patients, 65% had isolated aortic stenosis, 34% mixed disease, and 1% isolated aortic insufficiency. The one-year mortality rate using 51 Sapiens and 91 CoreValves was around 10.5%. Aortic valve areas and gradients were similar. Around 20% of patients required a pacemaker implant. Short- and intermediate-term analyses demonstrated a high incidence of postimplant aortic insufficiency of greater than 20%, depending on the preprocedural amount of aortic insufficiency, type of bicuspid pathology, and what type of device was employed. The CoreValve demonstrated a higher incidence of aortic insufficiency. Exercise caution here in interpretation, though. The implant techniques have greatly morphed since the earlier enrollment in this study.

In his concluding remarks, Mylotte emphasized that a large number of patients were implanted prior to routine computed-tomography (CT) utilization and strongly recommended that CT-based sizing always be employed. When asked if he thought programs should include bicuspid valves, he quipped, "We are probably treating them already, whether we really know it or not," hinting at the difficulty one is often faced with imaging a chunky calcified valve with severe leaflet immobility.

I especially appreciated Mylotte's information. It was during his presentation years ago that I gained the courage to consider a TAVR for my father when the time finally came. The enthusiasm of the world's experts for this procedure fostered the expertise of excellent teams at Vanderbilt University in Nashville, TN and Jewish Hospital in Louisville, KY that have served my family and my patients so well.

Because of this bold step forward in the potential expansion of application of TAVR, shall we begin to consider TAVR for bicusps the world over?

Hmm. . . . Stand by for part 2 of the TAVR–SAVR presentation.


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