10/9/2018

“Structural … If you rebuild it they will come… home” Vicki Norton, APRN Bryan Heart

Structural Heart

Objectives: • Define Structural Heart and the principles of a Structural Heart Program • Discuss the scope of • Differentiate between different procedures done for Structural Heart

Structural Heart Disease • Defining Structural Heart Disease: – “Of , relating to, or affecting structure” (1) – “any abnormality, or defect, of the heart muscle or the heart valves” (2) – “non-coronary processes and related interventions” (3)

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Structural Heart Volumes

Structural Heart Program Principles • Development of formalized Multidisciplinary Team – Co-directors: Dr. Steuter/Dr. Johnson – CT surgeons: Dr. Oakes, Thompson and Shelstad – Addition of Dr. Singsank • Addition of APP and structural heart navigator- Valve Clinic – Helps to streamline the workup process – Follow patients at 1 month and 1 year – Access for referrals streamlined

Structural Heart Program Principles • Weekly meeting to discuss cases and outcomes • Participate in registries • Turnaround time to procedure – Addition of Hybrid room • Ability to do multiple cases – MAC utilization increased – Impact on ICU beds

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Scope of Structural Heart disease

Steinberg et all, 2010

Valvular Heart disease • Aortic – TAVR (Transcatheter Replacement) • Mitral Regurgitation – Mitral Clip • PFO – Closure devices

Aortic Stenosis • Increasing numbers with our aging population • Non Rheumatic • Most common acquired valvular disorder • Surgery currently remains the “gold” standard • Significant number of patients at intermediate or high risk • Given their comorbid conditions need alternative therapies • TAVR – Transcatheter Aortic Valve replacement

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TAVR • Who is a candidate: • Stage D1: Severe High Gradient Aortic Stenosis – Aortic valve area ≤ 1.0 cm 2 with Aortic velocity 4.0 m/s which corresponds to Mean gradient of 40 mm Hg or higher • Stage D2: Low -flow Low -Gradient Aortic Stenosis with reduced LVEF – AVA ≤ 1.0 cm 2 ; Aortic velocity is < 4.0 m/s at rest but increases to at least 4.0 m/s with low- dose Dobutamine stress Echo • Stage D3: Low-Flow low-gradient with normal LVEF – AVA ≤ 1.0 cm 2 with Aortic velocity < 4.0 m/s and mean gradient < 40 mm Hg. – Challenging – indexed Aortic valve area of ≤ -.6 cm 2 /m 2 , a volume index < 35 ml/m 2

TAVR Evaluation

• Referral to Structural Heart Team • Discussion at TAVR meeting • Appointment with APP • Preparing for your procedure • Begin evaluation • Follow-up with Structural Heart • TEE/TTE Team at 1 month and 1 year. • Cardiac Catheterization or Stress test • CTA-TAVR protocol • Carotid Doppler's • Arterial Studies • 2 Surgeon evaluation • PT/OT • PFTs

Mitral Regurgitation • Surgical therapy has been the mainstay for treating patients • Percutaneous approach is currently being studied with a myriad of devices • Edge to Edge repair method first developed in the 1990s • Mitral leaflet coaptation using a clip is the only system currently approved by the FDA

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Mitral Clip Evaluation

• Referral to Structural Heart Team • Evaluation: • Appointment with APP • TEE • 1 surgical evaluation • Are you a candidate: • TTE within 6 months • Severe Degenerative/Functional PFTs MR • • Cardiac PET/CT or Cath • Failing Maximal therapy for • Non Contrast chest CT • Anatomically amendable to clip • Carotid Doppler's placement • Venous duplex lower extremities • Discussion at Structural Heart Meeting

COAPT A Randomized Trial of Transcatheter Leaflet Approximation in Patients with Heart Failure and Secondary Mitral Regurgitation Gregg W. Stone, MD On behalf of Michael Mack, William Abraham, JoAnn Lindenfeld and the COAPT Investigators

Tctmd 2018

Tctmd 2018

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Conclusions • In pts with HF and moderate-to-severe or severe secondary MR who remained symptomatic despite maximally-tolerated GDMT, transcatheter mitral leaflet approximation with the MitraClip was safe, provided durable reduction in MR, reduced the rate of HF hospitalizations, and improved survival, quality-of-life and functional capacity during 24-month follow-up • As such, the MitraClip is the first therapy shown to improve the prognosis of patients with HF by reducing secondary MR due to LV dysfunction

PFOs • Congenital Tunnel between the right and left atrium • Typically closes soon after birth, in a majority of people; fully closed within 2 years • PFOs have been identified as a source for cryptogenic ischemic stokes in approximately 15 to 25% of patients • Important to evaluate for other causes: – AF; Carotid disease; LAA • Controversy existed regarding safety and efficacy of various closure devices • Previously no randomized trials • RESPECT Trial

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Benefits vs Risk assessment • FDA panel noted: – Only modest reduction in the risk of recurrent stroke vs medical therapy – Patients with cryptogenic stroke due to paradoxical would benefit from closure – Identifying these patients is very challenging – Suggested a need for careful evaluation by a neurologist and cardiologist • Referred to Structural Team • Dr. Johnson/Singsank evaluate patient

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Amplatzer Device

Conclusion • Program strengths – Valve Clinic with dedicated APP/Navigator – Access for patients – Close monitoring of outcomes • Interventional management of structural heart disease will continue to increase as technology improves • Emerging areas of future growth – Low risk TAVR – Mitral/Tricuspid valves – Valve in valve – Stroke prevention

References 1. Merriam-Webster. Structural. www.merriam-webster.com 2. The society of Cardiac Angiography and Intervention 3. Steinberg DH, Staubach S, Frank J, et al. Defining structural heart disease in the adult patient: current scope, inherent challenges and future directions. Eur Heart J suppl 2010;12 Suppl E;E2-9. 4. www.ACC/AHA guidelines 5. tctMD. Transcatheter Cardiovascular Therapeutics 2018 6. New England Journal of ; Volume 377(11): 1022-1032; September 2017

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