TAVI Update

Introduction

• Speaker opens with a humorous statement about weather and personal reflections.

• Notes that TAVI (Transcatheter Aortic Valve Implantation) use for pure aortic valve regurgitation is currently off-label.

Farming Analogy

• Discusses personal life as a "farmer" in Minnesota with a hay field.

• Introduces a metaphor regarding the necessity of using the right tools for different tasks:

  • Pitchfork for Hay: Represents TAVI valves designed for tricuspid aortic valves.

  • Potato Fork for Potatoes: Represents the distinct requirements for bicuspid aortic valves.

TAVI Valves Development

• Discusses a slide from Mount Sinai with 32 TAVI valves that were all designed for three-cusp aortic valves, emphasizing:

  • Lack of valves designed specifically for bicuspid valves (potato forks).

  • Most operations performed on patients with aortic stenosis relate to three-cusp valves.

  • Highlights the financial investment and limited market for bicuspid aortic valve studies.

Calcification Characteristics

• Illustrates and contrasts:

  • Tricuspid Valve: Uniform calcification providing structural stability.

  • Bicuspid Valve: Asymmetrical calcification, potentially complicating valve placement.

• Size variations observed in bicuspid valves:

  • Maximum diameters differ: Tricuspid (26mm) vs. Bicuspid (30mm).

  • Bicuspid valves tend to be larger than tricuspid valves, complicating sizing for TAVI.

Sizing Challenges for TAVI

• Challenges arise from:

  • Risk of valve migration or paravalvular leak due to incorrect sizing.

  • Bicuspid valves often non-tubular shapes lead to sizing difficulties.

    

• Consequences of improper sizing:

  • Possibility of rupture during valve inflation.

  • Asymmetric inflow may complicate deployment of the TAVI device.

Aortic Valve Calcium Scores

• Highlights comparative data on valve calcification from tricuspid vs. bicuspid:

  • Tricuspid Generally average 3000 vs. Bicuspid average is 5000.

  • Implications for stroke risk related to calcification patterns (increased calcification typically = increased risk for disruption and therefore increased stroke risk).

Risks Associated with Bicuspid Valves

• Emphasizes:

  • Increased risk of aortic root rupture due to calcification.

  • Potential for postoperative complications such as aortic dissection post-TAVI.

Comparative Outcomes: Surgical vs. TAVI

• Presents data from over 11,000 patients regarding:

  • Increased risk of stroke and mortality linked to TAVI in bicuspid cases.

  • Shows long-term outcomes where surgery outperforms TAVI (in bicuspid valve cases) despite initial advantages.

• Suggests misapplication of tricuspid valves to cases requiring bicuspid solutions.

  

Cerebral Protection and Surgical Considerations

• Mentions challenges in using cerebral protection devices for patients.

• Discusses the necessity of collaborative discussions between surgeons and interventional cardiologists.

Aortic Valve Regurgitation Considerations

• Shares features of regurgitant aortic valves:

  • Lack of calcification challenges secure valve placement during TAVI.

  • Higher risk of valve embolization and migration observed across study settings.

    

Emerging Valve Technologies

• Introduces two new valves - Jena and J valves designed for aortic valve regurgitation:

  • Similar lock mechanisms to minimize migration risks.

  • Presents ongoing need for data on effectiveness and safety.

Summary of Findings

• Current TAVI valves are not prepared for bicuspid anatomy or pure aortic valve regurgitation:

  • Suggests standard surgical aortic valve replacement remains preferred for bicuspid cases.

  • Notes potential but unproven niche value for newer Jena and J valves in regurgitation cases.

• Highlights limitations in valve size options in relation to patient anatomy.

Conclusion

• Concludes with a poetic metaphor about tranquility and spirituality amidst agricultural life.

• Invites questions and reflections.