TAVR in Low Risk Patients:Case Presentations

Chad Kliger MD MS

Western Regional Director, Structural Heart Disease

Assistant Professor of Cardiology, Hofstra School of Medicine

Lenox Hill Heart and Lung, Northwell Health

DisclosuresWithin the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.

Consulting Fees/Honoraria Medtronic, Edwards Lifesciences

Siemens Healthineers, Philips Healthcare

Low Risk TAVR #1

• 71yo female with HTN, HLD, DM2 on oral meds

• Hx of GIB 8yrs ago without recurrent Hgb 10.3

• Asthma, last hospitalization 1yr ago in setting of URI

• Presents with progressive dyspnea on exertion – NYHA III

• STS 1.86% for isolated SAVR

Low Risk TAVR #1

• Severe AS by TTE, mean gradient 43mmHg, AVA 0.5cm2/m2

• Cath revealed non-obstructive CAD with 30% mid LAD; PA pressure 21mmHg

Low Risk TAVR #1

• Annulus:• Major/min diameter 18.4/24.4mm

• Perimeter 67.5mm

• Area 345mm2

• SoV >27mm

• LVOT: 65mm perimeter

• Membranous septum: 3mm

Low Risk TAVR #1

• Rt iliofemoral >6mm

• Lt iliofemoral >6mm

• Type I aortic arch

Low Risk TAVR #1 – Baseline EKG

• NSR with LVH

• But…patient focused on potential need for PPM

• Proceed with TAVR

• 20/23mm S3 vs 26mm CV Evolut Pro

Low Risk TAVR #1 TAVR

Gueta et al AJC 2011.

• 26mm CV Epro

• Implantation depth 3mm

• No PVL

• Hemos:• <2mmHg

peak/mean

• TTE mean 5mmHg

Low Risk TAVR #1 – Post-TAVR EKG

• Intra-op, immediately post-TAVR

• QRS 160ms

• 3hrs post-TAVR, stable to POD#2

• QRS 120ms

Low Risk TAVR #1 TAVR and Conduction

• New LBBB and Recovery of LVEF

Nazif et al. EHJ 2014.

• New LBBB and cardiac mortalityRiqueiro et al, CCI 2016.

Low Risk TAVR #1 Long-term PPM Complications

Palmisano et al, Europace 2013.

SURTAVI, Reardon et al NEJM 2017.

Low Risk TAVR #1

• Stable EKG, no events on telemtry

• No nodal blockers

• Decision made to send patient on real-time event monitor for 30d

• No events on monitor

• 1yr follow-up, pt doing well

Kliger et al US Cardiology Review 2018.

Low Risk TAVR #2• 70yo male with PMHx of

• HTN, HLD

• Afib, stopped eliquis 3mo ago for rectus sheath bleed – Hgb 5

• Presents with SOB NYHA III

• STS 1.4% for isolated SAVR

• TTE revealed severe AS mean gradient 40mmHg, AVA 0.9cm2/AVAi 0.5cm2/m2, nml EF, mild AI

• CHADS2-VASc 3 (3.2%) HAS-BLED 3 (5.8%)

Low Risk TAVR #2

• Annulus:• Major/min diameter 23.2/28.5mm

• Perimeter 84.9mm

• Area 539mm2

• LVOT: Ca+2, 85.2mm perimeter

• SoV >33mm

• No thrombus/filling defect in LAA

Low Risk TAVR #2

• Rt iliofemoral >8mm

• Lt iliofemoral >6mm

• Type II bovine aortic arch

Low Risk TAVR #2 TAVR

• Given LVOT Ca+2, BAV using 20mm TrueFlow balloon

• Sentinel Embolic Protection placed

• 34mm CV Evolut R

• Implantation depth 4mm

• Mild PVL

• Hemos:

• <2mmHg peak/mean

• TTE mean 8mmHg

Low Risk TAVR #2 TAVR

Reardon et al, NEJM 2019

Low Risk TAVR #2 TAVR

Gueta et al AJC 2011.

Low Risk TAVR #2 1mo Post-TAVR

• Started on plavixmonotherapy for 1mo

• Returning in 1wk for LAA closure

Thank Youckliger@northwell.edu