Interventional choice for the Aortic Stenosis Patient: SAVR, TAVR, or BAV Peter M. Pollak MD ©2011 MFMER | 3138928-1 ©2012 MFMER | 3208595-2 Disclosure Relevant Financial Relationship(s) • None Off Label Usage • None Outline • Aortic Stenosis population spectrum • Matching the treatment with the patient • TAVR vs. Medical Therapy • Surgical AVR vs. TAVR • Choosing a TAVR Valve • Role of Balloon Aortic Vavluloplasty ©2011 MFMER | 3138928-3 Natural History of Aortic Stenosis 0 20 40 60 80 100 40 50 60 70 80 Age (years) Survival (percent) Increasing obstruction, myocardial overload Average Age Death Latent Period Symptoms 40 50 60 70 80 from Ross and Braunwald, Circulation 1968;38:V-61 100 80 60 40 20 0 Natural History of Aortic Stenosis 0 20 40 60 80 100 40 50 60 70 80 Age (years) Survival (percent) Increasing obstruction, myocardial overload Average Age Death Latent Period Symptoms 40 50 60 70 80 from Ross and Braunwald, Circulation 1968;38:V-61 100 80 60 40 20 0 30% of Patients with Severe Symptomatic AS are “Untreated”! 59 68 70 40 52 69 55 41 32 30 60 48 31 45 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Bouma 1999 Iung* 2004 Pellikka 2005 Charlson 2006 Bach 2009 Spokane (prelim) Vannan (Pub. Pending) Severe Symptomatic Aortic Stenosis Percent of Cardiology Patients Treated AVR No AVR Under-treatment especially prevalent among patients managed by Primary Care physicians Reasons for non-treatment: 1. elderly 2. co-morbidities 3. patient refusal TAVR vs. Med Tx for Inoperable Patients Cardiovascular Mortality - ITT ©2011 MFMER | 3138928-7 PARTNER IA - Mortality (TAVR vs. SAVR) 0% 10% 20% 30% 40% 50% 60% 70% 0 6 12 18 24 30 36 All-Cause Mortality Months post Randomization TAVR AVR p = 0.483 26.8% 24.3% 34.6% 33.7% 44.8% 44.2% 0% 10% 20% 30% 40% 50% 60% 70% 0 6 12 18 24 30 36 All-Cause Mortality or Strokes Months post Randomization TAVR AVR All-Cause Mortality or Strokes (ITT) HR [95% CI] = 0.98 [0.79, 1.21] p (log rank) = 0.839 28.6% 27.4% 36.1% 36.9% 45.9% 47.1% 19.1% 4.5% Surgical 14.2% P = 0.04 for superiority 3.3% Transcatheter CoreValve vs. Surgery 1 Year All-cause Mortality [...]... MFMER | 3138928-20 Conclusions: Which approach for whom? • Aortic Stenosis remains lethal & undertreated • TAVR is life-saving in inoperable patients • Equivalency exists in high-risk patients • Surgical AVR remains treatment of choice for Low and Intermediate Risk patients • For now… suggestion of potential for superiority of TAVR • BAV for Palliation & Bridging • Utility in decision making? ©2011...Different Patient Populations? Age Male STS PROM NYHA III/IV 12 month TAVR Mortality 12 month SAVR Mortality CoreValve 83 yrs 53% PARTNER IA 84 yrs 57% 7.3% 86% 14.2% 11.8% 94% 24.3% 19.1% 26.8% ©2011 MFMER | 3138928-12 Intermediate risk trials ongoing… • SURTAVI – CoreValve • STS 4-10 randomized TAVR vs SAVR • Still enrolling • PARTNER... Incorrect Positioning – 1 vs 7 (2) Mod/Severe Prosthetic Regurgitation – 5 vs 22 ©2011 MFMER | 3138928-15 Valve Function is Similar ©2011 MFMER | 3138928-16 ©2011 MFMER | 3138928-17 BALLOON VALVULOPLASTY ©2011 MFMER | 3138928-18 Resurgence of interest in BAV EuroIntervention 2013;8:1388-1397 ©2011 MFMER | 3138928-19 Survival in BAV as Bridge ©2011 MFMER | 3138928-20 Conclusions: Which approach for . Interventional choice for the Aortic Stenosis Patient: SAVR, TAVR, or BAV Peter M. Pollak MD ©2011 MFMER | 3138928-1 ©2012 MFMER. Surgical AVR remains treatment of choice for Low and Intermediate Risk patients • For now… suggestion of potential for superiority of TAVR • BAV for Palliation & Bridging • Utility in. Outline • Aortic Stenosis population spectrum • Matching the treatment with the patient • TAVR vs. Medical Therapy • Surgical AVR vs. TAVR • Choosing a TAVR Valve • Role of Balloon Aortic Vavluloplasty