NUHS
National
University
Health System
TAVI: Asian
Perspective
Aortic stenosis in Singapore
Tay et al. SMJ 2012 (In press)
 Mean logistic euroscore: 10.7+/-12.3
 Refusal rate for open heart surgery
42.2%
Tay et al. SMJ 2012 (In press)
Unique challenges in Asian cohorts




Smaller annulus sizes
Smaller femoral sizes
Smaller LV cavity size
More frail?
Aortic root dimensions
Total
(n=249)
Degenerative
(n=216)
Rheumatic
(n=11)
Bicuspid (n=22)
P value
Annulus
20.3±2.0
20.2±1.9
20.7±1.3
21.2±2.5
0.045
Sinus
32.3±5.0
32.3±5.0
30.5±1.4
33.1±4.8
0.67
STJ
26.6±5.2
26.5±5.4
24.7±2.1
27.9±3.6
0.50
Ascending
Ao
33.9±5.9
33.6±6.0
30.2±4.2
36.4±4.6
0.11
Upper
Ascending
Ao
35.3±6.0
35.4±6.2
33.1±3.0
35.3±6.0
0.88
Aortic
dimensions
Tay et al . SMJ 2012 (In press)
Unique challenges in Asian cohorts
Smaller femoral sizes
Males
Females
Int J Cardiol 2012 (In press)
Patient
Age
Ethic
group
Gender
STS
score
EF
eGFR
Co-morbidities
1
72
Malay
Female
2.4
25
47
Cardiac cachexia
2
93
Eurasian
Male
14
70
18
Chronic obstructive lung disease.
3
80
Chinese
Male
3.1
50
60
Co-existent severe mitral regurgitation and low
boy weight (BSA1.4)
4
82
Malay
Male
4.2
33
38
Limited mobility from bilateral OA knee
5
86
Indian
Male
5.2
70
40
Limited mobility from bilateral OA knee
6
61
Chinese
Male
7.3
35
10
Previous CABG with patent saphenous vein grafts
7
84
Chinese
Female
8.8
45
51
Previous Ca breast with radiation. Low body
weight
8
84
Chinese
Male
4.7
65
47
Limited mobility
9
88
Chinese
Male
3.0
70
60
Concomittant thoracic aneurysm requiring TEVAR
10
78
Chinese
Female
4
75
54
BSA 1.4 (small size). Cardiac cachexia
11
92
Chinese
Female
12.4
69
50
12
82
Indian
Male
11.8
70
41
On chronic immune suppression
13
73
Chinese
Male
6.3
30
60
Previous CABG with patent saphenous vein grafts
14
79
Chinese
Female
7.7
60
47
Limited mobility and obesity
Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)
Patient
Annulus
(mm)
Femoral
artery size
(mm)
Access
Site
Valve
size
Length of
stay (days)
PVL
MR
30 day
mortality
1
19
4.1
TA
23
15
Trivial
Moderate►Mild-mod
Nil
2
24
4.4
TA
26
52
Mild
Mild (unchanged)
Nil
3
21
7.4
TF
23
10
Trivial
Severe►mod severe
Nil
4
24
6.4
TF
26
70*
Mild
Mild to mod►mild
Nil
5
21
7.2
TF
23
6
Mild-Mod
Mild (unchanged)
Nil
6
23
5.2
TA
26
9
Mild
Mild (unchanged)
Nil
7
20
5.6
TA
23
8
None
Mild (unchanged)
Yes
8
20
8.3
TF
23
6
Mild
Mild-mod►mild
Nil
9
24
7.8
TF
26
17
Mild-Mod
Mild (unchanged)
Nil
10
23
4.8
TA
26
12
None
Mild (unchanged)
Nil
11
21
6.2
TF
23
10
Mild
Mild►mild-mod
Nil
12
21
6.3
TF
23
17
Mild
Trivial (unchanged)
Nil
13
24
6.2
TA
26
7
Trivial
Mild to mod►mild
Nil
14
21
6.5
TF
23
33*
Mild
Mild (unchanged)
Nil
Tay & Hon. Asian Cardiovascular and Thoracic Annals 2012 (In press)
Improved
functional class
IV
III
II
I
Baseline
Reduction in
mean gradient
30 days
80
70
1
2
60
3
4
50
5
6
7
40
8
9
10
30
11
12
20
13
14
Tay and Hon. Asian Cardiovascular and Thoracic
Annals 2012 (In press)
10
0
baseline
Im m ediate post
1 m onth
3 m onth
6 m onth
1 year
Patient selection
 Patients are determined to be high risk
by two cardiac surgeons
 Reviewed by TAVI team
 Decision on TAVI and access
TAVI workup
 Traditional
• Coronary angiogram and right heart
catheterization+/- PCI
• Transthoracic and Transesophageal
echocardiogram
• CT coronary angiogram+aortogram
(including ileofemorals)
• US carotids, PFT, usual pre-op labs
• Determine angles of implant on the on day
of procedure
 Currently:
• Using CT to plan implant angles (if CT
available)
• Using DynaCT if implant angles not
available
• Using DynaCT and overlays if aortic
aneurysms present
Challenges (1)
 With diagnostic CT
• Pre-procedural CT with difficult imaging in
tachycardic patients/those who are in
failure/AF
• Renal failure patients an contrast concerns
(differences in Asian cohorts)
Challenges (2)
 DynaCT
• Need for rapid pacing and significant
volumes of contrasts
• ‘static’ overlays
The ideal situation
 Pre-procedure:Minimize pre-procedural
scanning/testing eg (1 test provide
annulus size, ileofemoral sizes, angle of
implant, coronary arteries, calcium
volume)
• Powerful pre-processing software
 Less contrast/less pacing
 ‘Dynamic/Live’ overlays
• Safe and effective procedural imaging
Clinical
Education
Research
Clinical
 First in Asia series published
 Maintain the highest quality of care for
valvular heart disease patients
 Standards and outcomes audited
according to international TAVI
benchmarks
Education
 Providing training for transcatheter
aortic valve implantation in Singapore
 Providing training to new operators and
regional centres in TAVI
 Incorporating TAVI and hybrid OT
technologies in imaging/interventional
meetings
 Fellowship and residency programmes
Research
 Diagnostic imaging (CT for sizing in
access sites Asian patients)
 Novel biomarker research into aortic
stenosis and TAVI
 Clinical trials and test site for second
generation TAVI valves
 Asian database for valvular heart
disease
Thank you