Seung-Jung Park
Asan Medical Center, Republic of Korea At AP VALVE & SH 2024 conference, Seung-Jung Park, MD (Asan Medical Center, Korea) marked the 15th year anniversary of pioneering Transcatheter Aortic Valve Replacement (TAVR) at AMC. Over this period, AMC has evolved from its initial procedures to becoming a leader in the field, consistently improving outcomes and expanding the range of patients who can benefit from TAVR.

Evolution of TAVR Guidelines and Clinical Practice

Since the pivotal 2010 PARTNER IB trial, TAVR has gained acceptance as a preferred treatment for patients with severe aortic stenosis, particularly those at high surgical risk. Recent trials, including the SMART trial, have further demonstrated TAVR's benefits in younger, lower-risk populations. The meta-analysis of low-risk TAVR trials involving over 2,000 patients shows that TAVR offers superior one-year mortality rates and cardiovascular outcomes compared to Surgical Aortic Valve Replacement (SAVR).

The 2020 ACC/AHA guidelines recommend TAVR as the first-line treatment for patients over 65 years old. While the ESC guidelines suggest TAVR primarily for patients over 75, with individualized assessments for those younger. However, real-world data shows a trend toward using TAVR in younger patients, with 78% of patients under 65 receiving TAVR in 2021-2022. This shift reflects a growing preference for tissue valves over mechanical ones, driven by TAVR's minimally invasive nature and favorable outcomes.

AMC's TAVR Success: The Role of Minimalist Approaches and CT Algorithms

AMC has now performed over 2,000 TAVR procedures, with a current rate of 300 cases annually. The center boasts a procedural success rate of 99.7%, low complication rates, and excellent one-year outcomes, including an all-cause mortality rate of 7.2% and a disabling stroke rate of less than 1%. This success is attributed to AMC’s heart team collaboration, a minimalist approach to anesthesia and patient care, and the precision of the AMC CT algorithm for device selection.

The AMC CT algorithm is a cornerstone of this success, allowing for meticulous pre-TAVR planning. By analyzing factors such as vascular access, aortic annulus size, calcium distribution, and coronary height, the team at AMC ensures optimal device sizing and placement. This approach has led to low rates of paravalvular leak (PVL) and permanent pacemaker implantation, particularly with the use of balloon-expandable devices, which are preferred for their strong radial force and predictable outcomes.

AMC continues to adapt its techniques to address complex cases, such as those involving bicuspid aortic valve stenosis, which typically involves higher calcium burdens and more challenging anatomies. In these cases, AMC has successfully applied its refined approaches, resulting in procedural outcomes comparable to those in tricuspid valve cases.

In-depth Analysis of the SMART Trial and its Implications on TAVR Practices

During the discussion of the SMART trial, particular focus was given to the management of patients with small aortic annuli (less than 430 mm²). The trial compared outcomes between self-expanding and balloon-expandable valves, with the latter using primarily 23mm devices. While both groups had similar clinical profiles, notable differences in procedural characteristics emerged. However, the device success rate was slightly lower compared to self-expanding valves.

At AMC, where approximately 40% of patients fit the SMART trial criteria, data showed a high procedural success rate and a significantly lower incidence of paravalvular leak (PVL) compared to the SMART trial. This discrepancy highlights the importance of meticulous device selection and sizing, particularly in patients with small annuli. AMC’s approach, which carefully considers factors like annulus size and calcium load, has proven effective in optimizing outcomes.

The differences between AMC’s outcomes and those of the SMART trial underscore the critical role of pre-TAVR planning using CT analysis. The SMART trial's use of relatively undersized devices without adequate consideration of calcium levels likely contributed to higher PVL rates. In contrast, AMC’s tailored approach, guided by detailed MDCT analysis, emphasizes the importance of precise device sizing to prevent complications.

Opening, Live Case & Lecture 1: TAVR

Thursday, August 08, 1:00 PM ~ 2:20 PM
Main Arena, Vista Hall 1, B2

Check The Session