TAVR: Incorporating Techniques into Daily Practice

SAN FRANCISCO, CALIF.—The advent of TAVR has substantially broadened the scope of surgical thinking toward incorporation of interventional techniques into daily practice, said Rudiger Lange, MD, PhD, from the German Heart Center Munich. In a presentation on Monday, he presented data from the Munich Heart Center TAVR registry and predicted more interdisciplinary treatment in the future that includes cardiologists and surgeons working together.

According to Lange, about 45% of all isolated procedures on the aortic valve at his center are performed with transcatheter techniques, with no difference in terms of survival between transfemoral and transapical patients. Based on analyses of patient quartiles according to the time period of the procedure, the 30-day mortality data revealed a threefold reduction (11.4% to 3.8%) between the first (earliest) and fourth (most recent) quartiles. Six-month mortality data revealed a two-fold reduction (23.5% to 12.4%) from the first to fourth quartile. Lange suggested this is likely due to operating on lower-risk patients; fewer complications support this hypothesis.

“We saw a considerable reduction in complications, especially vascular complications and prosthesis malplacement,” Lange said (see Figure).  Patients also present with less aortic regurgitation, according to Lange.

“Less than 10% show regurgitation that is moderate or higher, and most of the patients have only minimal or paravalvular leakage for both the CoreValve and the Sapien valve,” Lange said. “We also saw no stent fractures, no valve thrombosis, no valve degeneration and one patient was re-operated on for endocarditis.”

Excitement for new devices

In addition to TAVR, the German Heart Center offers many surgical treatment options that include surgical aortic valve replacement, the Ross procedure, suture-less aortic valve replacement, aortic valve and root reconstruction and transcatheter aortic valve  in surgical aortic valve (TAV-in-SAV) implantation. The center is now using second-generation transapical valves, including a pivotal CE mark study currently underway that utilizes the Medtronic Engager.

The potential advantages of the transapical valves include the fact that they are anatomically oriented and have a predefined implantation height that might avoid coronary obstruction and misplacement, Lange explained. Lange also said the center recently changed the access point for the transaortic Sapien valve and CoreValve to use an alternative site.

“We changed to a mini right anterior lateral thoracotomy and we do an extra incision for the introducers to have a better angle for the implantation,” Lange explained.

The center now also performs hybrid procedures during which the cardiologist works closely with the surgeon and new imaging techniques that include a CT scan and angiographic image overlay and a DynaCT scan with angiographic image overlay.