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Safety and efficacy of transcatheter aortic valve implantation compared with surgical aortic valve replacement in older high-risk patients with severe aortic stenosis - a single centre study
Abstract
S300
. may be a useful tool in identifying those high-risk patients ... .. who need aggressive therapy. .. .. .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.439 .. .. 439 .. .. .. .. Rotablation to treat heavily calcified .. coronary vessels in a patient with .. .. significant co-morbidities .. .. .. D. Chee ∗ .. .. .. Alfred Health, VIC, Australia .. .. . Rotational atherectomy (rotablation) has been shown to .. . be useful in treating heavily calcified coronary vessels. We ... . report a 72-year-old male with a past history of ischaemic ... heart disease and other co-morbidities who presented for elec- ... . tive coronary angiogram in a tertiary centre on a background ... of a strongly positive thallium stress test in the LAD terri- ... . tory. Angiogram showed a severe calcified 80% stenosis in ... the proximal-mid LAD vessel just after a high D1 that con- ... . tains 60% ostial disease and supplies a large territory. There ... is a further 70% mid LAD stenosis and further moderate- ... . severe diffuse distal disease. The RCA is dominant with a ... . severe 80% distal stenosis and severely diffusely diseased .. . PLV. An attempt to pass a 1.25x6mm balloon across the calcific ... . lesion in the LAD for stenting was unsuccessful and aban- ... doned. Options of Coronary Bypass Graft Surgery (CABG) ... . and percutaneous coronary interverntion (PCI) with rotab- ... lation were discussed. In view of patient’s co-morbidities, ... . another attempt with rotablation was performed. Rotabla- ... tion was then performed with a 1.25 burr then 1.5 burr to ... . the LAD lesion. The mid and proximal portions of the lesion ... were then successfully stented with bare-metal stents. This ... . illustrates the role of rotablation in patients who have chronic ... . narrowing or atheroma in the coronary vessels in compar- .. . ison to the conventional methods. Patients with significant ... . co-morbidities are also at risk from more invasive interven- .. . tion such as CABG. We advocate for hospital institutions to ... . incorporate PCI +/- rotablation in patients with challenging ... .. calcified lesions in the coronary circulation. .. .. .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.440 .. .. .. 440 .. .. .. Routine debulking rotational atherectomy .. preparation before drug eluting balloons .. .. for the management of in-stent restenosis .. .. 2 1,2,∗ 1 .. D. Vickers , D. Robaei , A. Carlyle , .. .. A. Lau 1,2 , R. Giles 1 , S. Ooi 1,2 , M. Pitney 1,2 , .. 1,2 N. Jepson .. .. .. 1 Eastern Heart Clinic, Prince of Wales Hospital, .. .. Randwick, Sydney, NSW, Australia .. 2 University of New South Wales, Randwick, .. .. Sydney, NSW, Australia .. .. .. Aim: To demonstrate the safety and efficacy of routine ... . debulking rotational atherectomy before drug eluting balloon ..
(DEB) deployment in the management of in-stent restenosis (ISR). Methods and Results: Eighteen patients with ISR totalling 28 lesions were treated with DEB following rotablation between December 2010 and November 2014. The mean age was 66.3 years (range 18-80). 83% of patients were male and 33% diabetics. The vessel treated was the circumflex in 39%, RCA in 25%, LAD in 22%, intermediate in 7% and diagonal in 7%. Lesion complexity was 50% type B2, 39% type C, and 11% type B1. Lesions were long (>20mm) in 14%, CTOs in 4% and bifurcational in 61%. The average lesion length was 13.6mm. Device failure occurred in 4% due to inability to deliver the DEB to the target lesion (n=1). On hospital discharge 89% of patients were on aspirin, and 89% on clopidogrel. Mean and median follow-up were 16 months and 24 months respectively, with 12 and 24-month follow-up in 83% and 56%. There were no cases of death or myocardial infarction during followup or in hospital. Target lesion failure occurred in two lesions (7%) in a circumflex bifurcation. ISR in this bifurcation was recurrent despite five treatments with rotablation and DEB, three to the main vessel and two to the side branch. There were no other instances of target lesion failure. Conclusion: Experience at our centre suggests that DEB following routine rotablation may be a safe and effective treatment option for in-stent restenosis in most cases. http://dx.doi.org/10.1016/j.hlc.2015.06.441 441 Safety and efficacy of transcatheter aortic valve implantation compared with surgical aortic valve replacement in older high-risk patients with severe aortic stenosis - a single centre study V. Wilson ∗ , T. Wong, P. Tamuno, S. Pasupati, R. Nair Waikato Hospital, New Zealand Introduction: Transcatheter Aortic Valve Implantation (TAVI) is a viable alternative for patients with aortic stenosis (AS) deemed unsuitable for surgical Aortic Valve Replacement (sAVR). Older patients with high clinical risk undergo sAVR after subjective assessment. Objective: Compare in-hospital recovery time and outcome for high-risk patients undergoing sAVR vs. TAVI from January 2010 to February 2014 at a New Zealand regional centre. Methods: Retrospective data was collected for patients undergoing TAVI (trans-femoral / subclavian) and patients over 75 years of age undergoing sAVR from January 2010 February 2014 at Waikato hospital. Length of hospital stay (LOS) during index admission, 30-day and 1-year mortality were analysed for TAVI and sAVR patients risk stratified based on Logistics Euroscore (≥12). Results: There was no significant difference in age (79±7 v 80±3 years) or gender distribution (34% v 39% females) between TAVI (n=90), and high-risk sAVR (n=71) groups. Compared with TAVI, high-risk sAVR group had longer LOS (5.6±2.5 v 8.5±4.4 days, p < 0.0001) and increased mortality at 30 days (3% v 8.4%) and 1 year (11% v 14%). LOS was longer
Abstract
S301
.. .. pre-treatment, but not with prasugrel. As institutional surgi.. cal revascularisation rates increased, the magnitude of benefit .. .. decreased with ticagrelor and clopidogrel. Time to coronary .. .. angiography had no correlation to net clinical benefit. .. Conclusion: The findings of our analysis suggest that pre.. .. treatment may not be universally beneficial and a tailored .. .. assessment of each patient’s individual ischaemic and bleed.. .. ing risk may identify those most likely to benefit. .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.442 .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.443 442 .. .. 443 .. Should P2Y12 inhibitors be administered .. .. Simple vs. complex coronary intervention: empirically in Non-ST-Elevation Acute .. .. impact on radiation exposure to the patient Coronary Syndrome management prior to .. .. and operator coronary angiography? A decision-making .. analysis into the value of pre-treatment .. .. J. Crowhurst 1,2,∗ , M. Whitby 1 , D. .. Murdoch 1,2 , C. Raffel 1 , A. Lee 1 , E. Shaw 1 , ∗ J. Gunton , T. Hartshorne, A. Chuang, D. .. .. D. Walters 1,2 Chew .. .. 1 .. Flinders Medical Centre- Cardiology The Prince Charles Hospital, Chermside, QLD, .. Department, Adelaide, SA, Australia .. Australia .. 2 University of Queensland, Brisbane, QLD, .. Background: Current guidelines recommend pre- ... Australia . treatment with a P2Y12 inhibitor for all patients with ... non-ST-elevation acute coronary syndrome (NSTE-ACS) ... Introduction: Invasive percutaneous coronary interven. before the coronary anatomy is known, however there are no ... tion (PCI) has developed greatly over the last 20 years. As . randomised trials to support this practice. We put forward a .. the procedures become longer and more complex, the radia. new approach to the question of pre-treatment by applying ... tion exposure to the patient and the operator also increases. . a decision-making analysis based on the available evidence ... This study aimed to quantify the difference between simple .. and complex PCI in terms of radiation dose to the patient and from randomised trials. .. Methods: A decision analysis model was constructed com- ... the primary operator. paring the three different P2Y12 inhibitors in addition to ... Methods: Between August and November 2014, radiation . aspirin in patients with NSTE-ACS. Based on clinical trial ... dose to the patient was measured using a calibrated dose data, the cumulative probability of 30-day mortality, myocar- ... area product (DAP) metre in the angiography X-ray system. . dial infarction (MI) and major bleeding were determined, ... Dose to the primary operator was measured using a digital and subsequently used to calculate the net clinical benefit. ... dosimeter (InstadoseTM ) that was read after each procedure. . Sensitivity analysis was performed to assess the relationship ... Other measures collected were patient weight, contrast media . between net clinical benefit and ischaemic risk, bleeding risk, .. volume and fluoroscopy time. Simple PCI was determined .. .. as single vessel intervention that did not require additional time to angiography and surgical revascularisation rate. . Results: Pre-treatment with ticagrelor and clopidogrel was ... equipment to a guide wire, balloon and stent. Complex PCI associated with net clinical benefit in patients at all levels of ... was determined as multi vessel intervention, chronic total . ischaemic risk except those in the lowest quartile (GRACE ... occlusions, intervention to vein grafts or single vessel interscore 0-3%) whereas prasugrel resulted in no net benefit at all ... vention that required the use of rotablation, intra-vascular . levels of ischaemic risk. Increasing bleeding risk was associ- ... ultrasound or optical coherence tomography. ated with net clinical benefit with ticagrelor and clopidogrel ... Results: See table: means (95% CI) .. .. .. . N= Weight (Kg) DAP (Gycm2 ) Fluoro...time (minutes) Contrast media (cc) Operator dose (Sv) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Overall 185 87 (86-87) 126 (122-128) 22.0 (21.3-22.6) 185 (188-182) 45.9 (48.4- 43.4) .. .. . Simple 119 88 (84-91) 106 (96-116) 17.5 (15.6-19.4) 173 (184-163) 40.5 (49.4- 31.6) .. .. . Complex 66 84 (79-88) 158 (136-181) 29.9 (25.1-34.7) 204 (205-230) 55.9 (74.1- 37.7) .. . P-value 0.176 <0.001 <0.001 0.009 0.094 in low-risk sAVR (n=135) group compared to TAVI (7.8±3.3 v 5.6±2.5; p < 0.0001) with similar 30-day mortality (2% v 3%). High-risk sAVR had older patients compared to lowrisk sAVR group (80.6±3.8 v 79±3 v, p = 0.001) with higher mortality at 30 days (8.4% v 2%) and 1 year (14% v 6%). Conclusion: sAVR is ideal for low-risk patients. TAVI is safer for older patients with higher clinical risk.
Conclusion: Despite the significantly higher radiation and fluoroscopy used in complex PCI, operator exposure was not significantly higher. http://dx.doi.org/10.1016/j.hlc.2015.06.444
S300
. may be a useful tool in identifying those high-risk patients ... .. who need aggressive therapy. .. .. .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.439 .. .. 439 .. .. .. .. Rotablation to treat heavily calcified .. coronary vessels in a patient with .. .. significant co-morbidities .. .. .. D. Chee ∗ .. .. .. Alfred Health, VIC, Australia .. .. . Rotational atherectomy (rotablation) has been shown to .. . be useful in treating heavily calcified coronary vessels. We ... . report a 72-year-old male with a past history of ischaemic ... heart disease and other co-morbidities who presented for elec- ... . tive coronary angiogram in a tertiary centre on a background ... of a strongly positive thallium stress test in the LAD terri- ... . tory. Angiogram showed a severe calcified 80% stenosis in ... the proximal-mid LAD vessel just after a high D1 that con- ... . tains 60% ostial disease and supplies a large territory. There ... is a further 70% mid LAD stenosis and further moderate- ... . severe diffuse distal disease. The RCA is dominant with a ... . severe 80% distal stenosis and severely diffusely diseased .. . PLV. An attempt to pass a 1.25x6mm balloon across the calcific ... . lesion in the LAD for stenting was unsuccessful and aban- ... doned. Options of Coronary Bypass Graft Surgery (CABG) ... . and percutaneous coronary interverntion (PCI) with rotab- ... lation were discussed. In view of patient’s co-morbidities, ... . another attempt with rotablation was performed. Rotabla- ... tion was then performed with a 1.25 burr then 1.5 burr to ... . the LAD lesion. The mid and proximal portions of the lesion ... were then successfully stented with bare-metal stents. This ... . illustrates the role of rotablation in patients who have chronic ... . narrowing or atheroma in the coronary vessels in compar- .. . ison to the conventional methods. Patients with significant ... . co-morbidities are also at risk from more invasive interven- .. . tion such as CABG. We advocate for hospital institutions to ... . incorporate PCI +/- rotablation in patients with challenging ... .. calcified lesions in the coronary circulation. .. .. .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.440 .. .. .. 440 .. .. .. Routine debulking rotational atherectomy .. preparation before drug eluting balloons .. .. for the management of in-stent restenosis .. .. 2 1,2,∗ 1 .. D. Vickers , D. Robaei , A. Carlyle , .. .. A. Lau 1,2 , R. Giles 1 , S. Ooi 1,2 , M. Pitney 1,2 , .. 1,2 N. Jepson .. .. .. 1 Eastern Heart Clinic, Prince of Wales Hospital, .. .. Randwick, Sydney, NSW, Australia .. 2 University of New South Wales, Randwick, .. .. Sydney, NSW, Australia .. .. .. Aim: To demonstrate the safety and efficacy of routine ... . debulking rotational atherectomy before drug eluting balloon ..
(DEB) deployment in the management of in-stent restenosis (ISR). Methods and Results: Eighteen patients with ISR totalling 28 lesions were treated with DEB following rotablation between December 2010 and November 2014. The mean age was 66.3 years (range 18-80). 83% of patients were male and 33% diabetics. The vessel treated was the circumflex in 39%, RCA in 25%, LAD in 22%, intermediate in 7% and diagonal in 7%. Lesion complexity was 50% type B2, 39% type C, and 11% type B1. Lesions were long (>20mm) in 14%, CTOs in 4% and bifurcational in 61%. The average lesion length was 13.6mm. Device failure occurred in 4% due to inability to deliver the DEB to the target lesion (n=1). On hospital discharge 89% of patients were on aspirin, and 89% on clopidogrel. Mean and median follow-up were 16 months and 24 months respectively, with 12 and 24-month follow-up in 83% and 56%. There were no cases of death or myocardial infarction during followup or in hospital. Target lesion failure occurred in two lesions (7%) in a circumflex bifurcation. ISR in this bifurcation was recurrent despite five treatments with rotablation and DEB, three to the main vessel and two to the side branch. There were no other instances of target lesion failure. Conclusion: Experience at our centre suggests that DEB following routine rotablation may be a safe and effective treatment option for in-stent restenosis in most cases. http://dx.doi.org/10.1016/j.hlc.2015.06.441 441 Safety and efficacy of transcatheter aortic valve implantation compared with surgical aortic valve replacement in older high-risk patients with severe aortic stenosis - a single centre study V. Wilson ∗ , T. Wong, P. Tamuno, S. Pasupati, R. Nair Waikato Hospital, New Zealand Introduction: Transcatheter Aortic Valve Implantation (TAVI) is a viable alternative for patients with aortic stenosis (AS) deemed unsuitable for surgical Aortic Valve Replacement (sAVR). Older patients with high clinical risk undergo sAVR after subjective assessment. Objective: Compare in-hospital recovery time and outcome for high-risk patients undergoing sAVR vs. TAVI from January 2010 to February 2014 at a New Zealand regional centre. Methods: Retrospective data was collected for patients undergoing TAVI (trans-femoral / subclavian) and patients over 75 years of age undergoing sAVR from January 2010 February 2014 at Waikato hospital. Length of hospital stay (LOS) during index admission, 30-day and 1-year mortality were analysed for TAVI and sAVR patients risk stratified based on Logistics Euroscore (≥12). Results: There was no significant difference in age (79±7 v 80±3 years) or gender distribution (34% v 39% females) between TAVI (n=90), and high-risk sAVR (n=71) groups. Compared with TAVI, high-risk sAVR group had longer LOS (5.6±2.5 v 8.5±4.4 days, p < 0.0001) and increased mortality at 30 days (3% v 8.4%) and 1 year (11% v 14%). LOS was longer
Abstract
S301
.. .. pre-treatment, but not with prasugrel. As institutional surgi.. cal revascularisation rates increased, the magnitude of benefit .. .. decreased with ticagrelor and clopidogrel. Time to coronary .. .. angiography had no correlation to net clinical benefit. .. Conclusion: The findings of our analysis suggest that pre.. .. treatment may not be universally beneficial and a tailored .. .. assessment of each patient’s individual ischaemic and bleed.. .. ing risk may identify those most likely to benefit. .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.442 .. .. http://dx.doi.org/10.1016/j.hlc.2015.06.443 442 .. .. 443 .. Should P2Y12 inhibitors be administered .. .. Simple vs. complex coronary intervention: empirically in Non-ST-Elevation Acute .. .. impact on radiation exposure to the patient Coronary Syndrome management prior to .. .. and operator coronary angiography? A decision-making .. analysis into the value of pre-treatment .. .. J. Crowhurst 1,2,∗ , M. Whitby 1 , D. .. Murdoch 1,2 , C. Raffel 1 , A. Lee 1 , E. Shaw 1 , ∗ J. Gunton , T. Hartshorne, A. Chuang, D. .. .. D. Walters 1,2 Chew .. .. 1 .. Flinders Medical Centre- Cardiology The Prince Charles Hospital, Chermside, QLD, .. Department, Adelaide, SA, Australia .. Australia .. 2 University of Queensland, Brisbane, QLD, .. Background: Current guidelines recommend pre- ... Australia . treatment with a P2Y12 inhibitor for all patients with ... non-ST-elevation acute coronary syndrome (NSTE-ACS) ... Introduction: Invasive percutaneous coronary interven. before the coronary anatomy is known, however there are no ... tion (PCI) has developed greatly over the last 20 years. As . randomised trials to support this practice. We put forward a .. the procedures become longer and more complex, the radia. new approach to the question of pre-treatment by applying ... tion exposure to the patient and the operator also increases. . a decision-making analysis based on the available evidence ... This study aimed to quantify the difference between simple .. and complex PCI in terms of radiation dose to the patient and from randomised trials. .. Methods: A decision analysis model was constructed com- ... the primary operator. paring the three different P2Y12 inhibitors in addition to ... Methods: Between August and November 2014, radiation . aspirin in patients with NSTE-ACS. Based on clinical trial ... dose to the patient was measured using a calibrated dose data, the cumulative probability of 30-day mortality, myocar- ... area product (DAP) metre in the angiography X-ray system. . dial infarction (MI) and major bleeding were determined, ... Dose to the primary operator was measured using a digital and subsequently used to calculate the net clinical benefit. ... dosimeter (InstadoseTM ) that was read after each procedure. . Sensitivity analysis was performed to assess the relationship ... Other measures collected were patient weight, contrast media . between net clinical benefit and ischaemic risk, bleeding risk, .. volume and fluoroscopy time. Simple PCI was determined .. .. as single vessel intervention that did not require additional time to angiography and surgical revascularisation rate. . Results: Pre-treatment with ticagrelor and clopidogrel was ... equipment to a guide wire, balloon and stent. Complex PCI associated with net clinical benefit in patients at all levels of ... was determined as multi vessel intervention, chronic total . ischaemic risk except those in the lowest quartile (GRACE ... occlusions, intervention to vein grafts or single vessel interscore 0-3%) whereas prasugrel resulted in no net benefit at all ... vention that required the use of rotablation, intra-vascular . levels of ischaemic risk. Increasing bleeding risk was associ- ... ultrasound or optical coherence tomography. ated with net clinical benefit with ticagrelor and clopidogrel ... Results: See table: means (95% CI) .. .. .. . N= Weight (Kg) DAP (Gycm2 ) Fluoro...time (minutes) Contrast media (cc) Operator dose (Sv) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Overall 185 87 (86-87) 126 (122-128) 22.0 (21.3-22.6) 185 (188-182) 45.9 (48.4- 43.4) .. .. . Simple 119 88 (84-91) 106 (96-116) 17.5 (15.6-19.4) 173 (184-163) 40.5 (49.4- 31.6) .. .. . Complex 66 84 (79-88) 158 (136-181) 29.9 (25.1-34.7) 204 (205-230) 55.9 (74.1- 37.7) .. . P-value 0.176 <0.001 <0.001 0.009 0.094 in low-risk sAVR (n=135) group compared to TAVI (7.8±3.3 v 5.6±2.5; p < 0.0001) with similar 30-day mortality (2% v 3%). High-risk sAVR had older patients compared to lowrisk sAVR group (80.6±3.8 v 79±3 v, p = 0.001) with higher mortality at 30 days (8.4% v 2%) and 1 year (14% v 6%). Conclusion: sAVR is ideal for low-risk patients. TAVI is safer for older patients with higher clinical risk.
Conclusion: Despite the significantly higher radiation and fluoroscopy used in complex PCI, operator exposure was not significantly higher. http://dx.doi.org/10.1016/j.hlc.2015.06.444