TAVI and the ascending aorta: Meeting the challenges

The aortic valve and the ascending aorta remain some of the most challenging spaces in vascular surgery, but every year brings new techniques, devices, and approaches.

On Tuesday morning, Dr. Lars Svensson of the Heart & Vascular Instituion at the Cleveland Clinic, and Dr. Nicholas Cheshire of Royal Brompton Hospital in London, will host a session devoted to capturing the cutting edge of this rapidly changing scene.

The session kicks off with Dr. Dietmar Koschyk of the University Hospital Hamburg (Germany) focusing on how well valve-in-valve transcatheter aortic valve implantation (TAVI) and mitral valve-in-valve endovascular repair are working.

“With aortic valve-in-valve re-implantations, what’s happening now is that patients, especially the younger patients are increasingly asking for biological valves for their first-time operation, with the idea that the next will be a valve-in-valve,” session moderator Dr. Svensson said. “You put in a tissue valve or aortic valve repair, always with the option that down the road these can be treated with a valve-in-valve stent.”

In the mitral valve space, “there were attempts to use various procedures to repair the mitral valve,” Dr. Svensson said, but the only ones to have really succeeded so far are mitral valve clips. Dr. Ted Feldman of Evanston Hospital, Northshore University HealthSystem, in Evanston, Ill., a pioneer in mitral valve clips, will look beyond them to bring surgeons up to date on technology and techniques.

“Coming down the line now are various new devices and procedures: artificial cords being put in through the left ventricle [and] various types of balloon spaces in the mitral valve in particular,” Dr. Svensson says. “The last I saw there were about 16 mitral valve replacement devices. So I think we’re going to find there will be a lot of options and it’s just a matter of finding out which work best.”

Dr. Feldman follows up with a broad update on TAVI, while Dr. Allan Stewart of Mount Sinai Medical Center in New York brings in an interventional cardiologist’s perspective.

“Increasingly, cardiologists and cardiac surgeons are working in teams, and for TAVIs we’ve worked together from the beginning,” Dr. Svensson notes. “We can support each other and bring our own backgrounds to deliver a better product for the patient.”

The second half of the session confronts issues specific to the ascending aorta, with Dr. Ralf Kolvenbach of Catholic Clinics Düsseldorf (Germany), presenting a global overview; Dr. Ali Khoynezhad of Cedars-Sinai Medical Center in Los Angeles, Calif., discussing endograft repair of ascending aortic lesions, and Dr. Carlos Donayre, of the University of California, Los Angeles, presenting on dissections.

Ascending stenting is challenging, but can be necessary for patients at higher risk, who cannot undergo standard surgery, or for those who have liver disease or cirrhosis and should not be placed on a heart lung machine, Dr. Svensson says.

“The tricky part is that you’ve got to deal with the coronary arteries,” he explains. “The sinotubular junction may be dilated, which may make it difficult to anchor an ascending stent graft proximally. Then you have to deal with the innominate artery coming off and you have to very accurately place an ascending stent graft.”

With acute dissections, which Dr. Kolvenbach will address in detail, “the challenge is to get the stent to completely obliterate the false lumen, not occlude the coronaries, and also preserve aortic valve function,” Dr. Svensson said. “So there is a place for it, and as we get new devices, I think things will get better over time.”

The session wraps with Dr. Grayson H. Wheatley III of Temple University School of Medicine in Philadelphia, exploring access routes new and old, along with the latest in off-the-shelf devices.

“We’ve used transapical, transaortic, transcarotid, transsubclavian artery, [and] transfemoral venous [devices],” Dr. Svensson said. “We’ve also done some patients where we’ve gone transfemoral venous, crossed from the inferior vena cava into the infer-renal aorta and then gone up the aorta that way.” Some of these approaches are not yet standard practice, he said, but still reasonable strategies for the right patients at highly skilled and experienced centers.

Session 1: Progress in Transcatheter Heart Valves and New Approaches to Ascending Aortic Disease

Tuesday, 6:45 a.m. – 7:43 a.m.

Grand Ballroom East, 3rd Floor

The aortic valve and the ascending aorta remain some of the most challenging spaces in vascular surgery, but every year brings new techniques, devices, and approaches.

On Tuesday morning, Dr. Lars Svensson of the Heart & Vascular Instituion at the Cleveland Clinic, and Dr. Nicholas Cheshire of Royal Brompton Hospital in London, will host a session devoted to capturing the cutting edge of this rapidly changing scene.

The session kicks off with Dr. Dietmar Koschyk of the University Hospital Hamburg (Germany) focusing on how well valve-in-valve transcatheter aortic valve implantation (TAVI) and mitral valve-in-valve endovascular repair are working.

“With aortic valve-in-valve re-implantations, what’s happening now is that patients, especially the younger patients are increasingly asking for biological valves for their first-time operation, with the idea that the next will be a valve-in-valve,” session moderator Dr. Svensson said. “You put in a tissue valve or aortic valve repair, always with the option that down the road these can be treated with a valve-in-valve stent.”

In the mitral valve space, “there were attempts to use various procedures to repair the mitral valve,” Dr. Svensson said, but the only ones to have really succeeded so far are mitral valve clips. Dr. Ted Feldman of Evanston Hospital, Northshore University HealthSystem, in Evanston, Ill., a pioneer in mitral valve clips, will look beyond them to bring surgeons up to date on technology and techniques.

“Coming down the line now are various new devices and procedures: artificial cords being put in through the left ventricle [and] various types of balloon spaces in the mitral valve in particular,” Dr. Svensson says. “The last I saw there were about 16 mitral valve replacement devices. So I think we’re going to find there will be a lot of options and it’s just a matter of finding out which work best.”

Dr. Feldman follows up with a broad update on TAVI, while Dr. Allan Stewart of Mount Sinai Medical Center in New York brings in an interventional cardiologist’s perspective.

“Increasingly, cardiologists and cardiac surgeons are working in teams, and for TAVIs we’ve worked together from the beginning,” Dr. Svensson notes. “We can support each other and bring our own backgrounds to deliver a better product for the patient.”

The second half of the session confronts issues specific to the ascending aorta, with Dr. Ralf Kolvenbach of Catholic Clinics Düsseldorf (Germany), presenting a global overview; Dr. Ali Khoynezhad of Cedars-Sinai Medical Center in Los Angeles, Calif., discussing endograft repair of ascending aortic lesions, and Dr. Carlos Donayre, of the University of California, Los Angeles, presenting on dissections.

Ascending stenting is challenging, but can be necessary for patients at higher risk, who cannot undergo standard surgery, or for those who have liver disease or cirrhosis and should not be placed on a heart lung machine, Dr. Svensson says.

“The tricky part is that you’ve got to deal with the coronary arteries,” he explains. “The sinotubular junction may be dilated, which may make it difficult to anchor an ascending stent graft proximally. Then you have to deal with the innominate artery coming off and you have to very accurately place an ascending stent graft.”

With acute dissections, which Dr. Kolvenbach will address in detail, “the challenge is to get the stent to completely obliterate the false lumen, not occlude the coronaries, and also preserve aortic valve function,” Dr. Svensson said. “So there is a place for it, and as we get new devices, I think things will get better over time.”

The session wraps with Dr. Grayson H. Wheatley III of Temple University School of Medicine in Philadelphia, exploring access routes new and old, along with the latest in off-the-shelf devices.

“We’ve used transapical, transaortic, transcarotid, transsubclavian artery, [and] transfemoral venous [devices],” Dr. Svensson said. “We’ve also done some patients where we’ve gone transfemoral venous, crossed from the inferior vena cava into the infer-renal aorta and then gone up the aorta that way.” Some of these approaches are not yet standard practice, he said, but still reasonable strategies for the right patients at highly skilled and experienced centers.

Session 1: Progress in Transcatheter Heart Valves and New Approaches to Ascending Aortic Disease

Tuesday, 6:45 a.m. – 7:43 a.m.

Grand Ballroom East, 3rd Floor

The aortic valve and the ascending aorta remain some of the most challenging spaces in vascular surgery, but every year brings new techniques, devices, and approaches.

On Tuesday morning, Dr. Lars Svensson of the Heart & Vascular Instituion at the Cleveland Clinic, and Dr. Nicholas Cheshire of Royal Brompton Hospital in London, will host a session devoted to capturing the cutting edge of this rapidly changing scene.

The session kicks off with Dr. Dietmar Koschyk of the University Hospital Hamburg (Germany) focusing on how well valve-in-valve transcatheter aortic valve implantation (TAVI) and mitral valve-in-valve endovascular repair are working.

“With aortic valve-in-valve re-implantations, what’s happening now is that patients, especially the younger patients are increasingly asking for biological valves for their first-time operation, with the idea that the next will be a valve-in-valve,” session moderator Dr. Svensson said. “You put in a tissue valve or aortic valve repair, always with the option that down the road these can be treated with a valve-in-valve stent.”

In the mitral valve space, “there were attempts to use various procedures to repair the mitral valve,” Dr. Svensson said, but the only ones to have really succeeded so far are mitral valve clips. Dr. Ted Feldman of Evanston Hospital, Northshore University HealthSystem, in Evanston, Ill., a pioneer in mitral valve clips, will look beyond them to bring surgeons up to date on technology and techniques.

“Coming down the line now are various new devices and procedures: artificial cords being put in through the left ventricle [and] various types of balloon spaces in the mitral valve in particular,” Dr. Svensson says. “The last I saw there were about 16 mitral valve replacement devices. So I think we’re going to find there will be a lot of options and it’s just a matter of finding out which work best.”

Dr. Feldman follows up with a broad update on TAVI, while Dr. Allan Stewart of Mount Sinai Medical Center in New York brings in an interventional cardiologist’s perspective.

“Increasingly, cardiologists and cardiac surgeons are working in teams, and for TAVIs we’ve worked together from the beginning,” Dr. Svensson notes. “We can support each other and bring our own backgrounds to deliver a better product for the patient.”

The second half of the session confronts issues specific to the ascending aorta, with Dr. Ralf Kolvenbach of Catholic Clinics Düsseldorf (Germany), presenting a global overview; Dr. Ali Khoynezhad of Cedars-Sinai Medical Center in Los Angeles, Calif., discussing endograft repair of ascending aortic lesions, and Dr. Carlos Donayre, of the University of California, Los Angeles, presenting on dissections.

Ascending stenting is challenging, but can be necessary for patients at higher risk, who cannot undergo standard surgery, or for those who have liver disease or cirrhosis and should not be placed on a heart lung machine, Dr. Svensson says.

“The tricky part is that you’ve got to deal with the coronary arteries,” he explains. “The sinotubular junction may be dilated, which may make it difficult to anchor an ascending stent graft proximally. Then you have to deal with the innominate artery coming off and you have to very accurately place an ascending stent graft.”

With acute dissections, which Dr. Kolvenbach will address in detail, “the challenge is to get the stent to completely obliterate the false lumen, not occlude the coronaries, and also preserve aortic valve function,” Dr. Svensson said. “So there is a place for it, and as we get new devices, I think things will get better over time.”

The session wraps with Dr. Grayson H. Wheatley III of Temple University School of Medicine in Philadelphia, exploring access routes new and old, along with the latest in off-the-shelf devices.

“We’ve used transapical, transaortic, transcarotid, transsubclavian artery, [and] transfemoral venous [devices],” Dr. Svensson said. “We’ve also done some patients where we’ve gone transfemoral venous, crossed from the inferior vena cava into the infer-renal aorta and then gone up the aorta that way.” Some of these approaches are not yet standard practice, he said, but still reasonable strategies for the right patients at highly skilled and experienced centers.

Session 1: Progress in Transcatheter Heart Valves and New Approaches to Ascending Aortic Disease

Tuesday, 6:45 a.m. – 7:43 a.m.

Grand Ballroom East, 3rd Floor