State of the art aortic valve surgery in the era of percutaneous valve interventions. (invited lecture 2009)

1. Surgical options for aortic stenosis F MAISANO

5. STS DATABASE AVR n 32,968 Mortality 4.0% Stroke 1.5% Prolonged Ventilation 7.07% Reoperation 4.12% Renal Failure 3.7%

6. MedPAR Data

7. Long term Outcomes Eichinger et al Annals thorac Surg 2008 Durability Survival

8. TAVI: a new tool for the high risk patients

12. 30% of elderly patients are denied surgery

13. Age and mortality Euroscore logistic risk for valve surgery assuming no comorbidities

15. Prevalence of valve disease: AS is epidemic in the elderly Nkomo et al , Lancet 2006

16. Risk benefit analysis in the elderly

18. Common comorbidities in older patients Condition implications Renal dysfunction Exacerbated by diuretics and ACE inhibitors Chronic lung disease Contributes to uncertainty about diagnosis /volume status Cognitive dysfunction Interferes with dietary, medication, activity compliance Depression , social isolation Worsen prognosis, interferes with compliance Postural hypotension, falls Exacerbated by vasodilators, diuretics,  blockers Urinary incontinence Aggravated by diuretics, ACE inhibitors (cough) Sensory deprivation Interferes with compliance Nutritional disorders Exacerbated by dietary restrictions Polypharmacy Compliance issues, drug interactions Frailty Exacerbated by hospitalization; increased fall risk

26. Euroscore overestimates the actual risk in the high risk population Osswald B, et al. European Heart Journal (2009) 30, 74–80

27. Leontyev et al Ann Thorac Surg 2009

29. Bicuspid vs tricuspid valve

30. Bicuspid Aortic Valve

31. Valve area and calcium detection

32. TAVI screening di 22

33. Valve Team Hsr Nov 2007-May 2009 82 TAVI 69 Transfemoral approach 10 Transapical approach 3 Trans-subclavian approach

34. Patient baseline clinical characteristics (n=82)

35. Procedural outcomes (n=82)

36. Survival Actuarial survival at 12 months: 88.1±4.3%

37. The SOURCE Registry Cohort One Survival Survival of TA pts with ES< and >20 are significantly different (93.4 vs. 88.1) (p=0.067) TF (n=459) TA (n=571) 30 day 93.7% 89.7% EuroSCORE <20 94.6% (Mean 12.5) 93.4% (Mean 12.4) EuroSCORE >20 93.3% (Mean 33.7) 63% of pts 88.1% (Mean 36.3) 70% of pts 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Fraction of Months post Procedure Survival < 20 >= 20 SOURCE 30 Day All Cause Mortality -- Transfemoral Approach Stratified by Logistic EuroSCORE SOURCE 30 Day All Cause Mortality -- Transapical Approach Stratified by Logistic EuroSCORE 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Fraction of Months post Procedure Survival < 20 >= 20 p=0.068

38. Patients entering the VALVETEAM screening process (n=181)

39. TAVI vs Surgical AVR

42. Surgical Approaches: Conventional and Minimally Invasive Cardiac Surgery Conventional Minimally Invasive

44. Conventional and Minimally Invasive Incisions Mitral Valve Surgery Aortic Valve Surgery

45. Soft Tissue Retractor Placement – Used For Exposures in Minimally Invasive Cardiac Surgery

47. Trans-incision Visualization – The Aortic Valve

48. AVR – CHOICE OF THE PROTHESIS

49. Barnett et al JTCVS 2009

50. The revalving concept

51. Expanding durabilty

54. Valve-X-change: the lifetime valve

56. Zlotnick et al Circulation 2008

57. Apicoaortic conduits

58. Edwards SAPIEN ™ THV