Dr. Ernesto M. Torresani - sanatoriomodeloquilmes.com€¦ · 0 2 4 6 8 10 12 14) 75 Enf Valvular...

Dr. Ernesto M. Torresani

0

2

4

6

8

10

12

14

<45 45-54 55-64 65-74 >75

Pre

vale

nce o

f m

od

or

seve

re V

HD

(%

)

Enf Valvular

Enf. Mitral

Enf. Valvular Aortica

> 75 años = 4 a 6%

Estenosis Aórtica. PREVALENCIA

Nkomo VT et al. Burden of valvular heart diseases: a population-based study.

Lancet 2006;368:1005-1011

PREVALENCIA = n° de casos en un punto específico de tiempo

Población Total

TAVI. Indicaciones y resultados

POBLACIÓN Argentina 2019

60 a 74 años

4.811.074 (10.70%)

> 75 años

2.161.303 (4.80%)

Estimadores y proyecciones de población.

Población estimada al 1° de julio de cada año.

Años 2010 al 2040.

AÑO 2019Total 44.938.712Grupo de edad

0- 4 3.726.162

05-sep 3.743.931

oct-14 3.542.513

15-19 3.508.965

20-24 3.548.389

25-29 3.522.333

30-34 3.287.553

35-39 3.141.871

40-44 3.027.334

45-49 2.579.461

50-54 2.241.959

55-59 2.084.864

60-64 1.879.409

65-69 1.631.170

70-74 1.311.495

75-79 945.129

80-84 627.708

85-89 364.728

90-94 166.561

95-99 48.440

100 y más 8.737

https://www.indec.gob.ar/indec/web/Nivel4-Tema-2-24-84


https://www.indec.gob.ar/indec/web/Nivel4-Tema-2-24-84

Esperanza de Vida Argentina 2014

Esperanza de Vida en Argentina a distintas edades

2014 Total Varones Mujeres

Al nacer 75,34 72,08 78,81

10 años 66,52 63,32 69,92

20 años 56,84 53,72 60,14

30 años 47,39 44,47 50,45

40 años 37,99 35,19 40,89

50 años 28,96 26,30 31,66

60 años 20,80 18,45 23,05

70 años 13,74 11,92 15,22

75 años 10,67 9,17 11,71

80 años 8,04 6,86 8,63

90 años 4,75 4,00 4,68

100 años 2,90 2,65 2,88

Población/Proyecciones y estimaciones/

Tablas de mortalidad 2008-2010

http://www.indec.mecon.ar/


https://www.worldometers.info/demographics/argentina-demographics/


Evolución de la Pirámide Poblacional en la Argentina

Pirámide Poblacional Argentina

https://www.worldometers.info/demographics/argentina-demographics/

0 1 2 3 4 5

100

50

0

Reemplazo Valvular

So

bre

vid

a (

%)

Años

Schwarz et al. The effect of aortic valve replacement on survival.

Circulation 1982;66:1105-1110.

p<0.05 p<0.001

Consulta Óbito 50%

Angina 35% 5 años

Sincope 15% 3 años

Disnea 50% 2 años

Estenosis Aórtica-TRATAMIENTOTAVI. Indicaciones y resultados

Alain Cribier

Percutaneous Transluminal Valvuloplasty of acquired aortic stenosis

in elderly patients. An alternative of valve replacement?

Lancet 1986;327(8472):63-67.

Setiembre 1985 – Valvuloplastia Aórtica

Percutánea

Estenosis Aórtica-VALVULOPLASTIATAVI. Indicaciones y resultados

Valvuloplastia Aórtica – Evolución

Block PC and Palacios IF. Aortic and Mitral Balloon Valvuloplasty: The United States Experience.

In Textbook of Interventional Cardiology. Topol EJ (2d Ed) 1994;Ch70:1189 -1205.

Estenosis Aórtica-VALVULOPLASTIATAVI. Indicaciones y resultados

Cribier A et al. Percutaneous Transcatheter Implantation of an Aortic Valve

Prosthesis for Calcific Aortic Stenosis. First Human Case Description.

Circulation 2002;106:3006-3008.

Estenosis Aórtica-TAVITAVI. Indicaciones y resultados

TAVI = TAVR

Smith CR et al, for the PARTNER Trial Investigators. Transcatheter vs. Surgical Aortic Valve

Replacement in High-Risk Patients. N Engl J Med 2011;364:2187-2198.PARTNER A

TAVI vs. Cirugía

PARTNER ATAVI. Indicaciones y resultados

2007 al 2009 699 pts

PARTNER B

Leon MB et al, for the PARTNER Trial Investigators. Transcatheter Aortic-Valve Implantation for

Aortic Stenosis in Patients Who Cannot Udergo Surgery.N Engl J Med 2010;363:1597-1607.

PARTNER B

INOPERABLES


2007 al 2009 358 pts

PARTNER B

Leon MB et al, for the PARTNER Trial Investigators. Transcatheter Aortic-Valve Implantation for

Aortic Stenosis in Patients Who Cannot Udergo Surgery.N Engl J Med 2010;363:1597-1607.

PARTNER B

Inoperables


PARTNER A

TAVI vs. Cirugía

PARTNER A

Kodali SK et al, for the PARTNER Trial Investigators. Two-Year Outcomes afterTranscatheter or

Surgical Aortic-Valve Replacement. N Engl J Med 2012;366:1686-1695.


PARTNER A y B

Kodali SK et al, for the PARTNER Trial Investigators. Two-Year Outcomes afterTranscatheter or

Surgical Aortic-Valve Replacement. N Engl J Med 2012;366:1686-1695.

Svensson LG et al. A comprehensive review of the PARTNER trial.

J Thorac Cardiovasc Surg 2013;145 (3 Suppl):S11-6.

CONCLUSIONS: The PARTNER A and B trials showed that survival has been remarkably

good, but stroke and perivalvular leakage require further device development.


PARTNER A y B

Nishimura RA et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular

Heart Disease. J Am Coll Cardiol 2014;63:e57–185.)

I – A: Reemplazo Quirúrgico en pacientes con riesgo bajo o intermedio.

I – B: TAVI en pacientes con riesgo quirúrgico prohibitivo.

I – C: En pacientes con alto riesgo quirúrgico el Heart Team debe decidir.

IIa – B: TAVI es razonable alternativa en pacientes con alto riesgo quirúrgico.


TAVI ¿Sólo para pacientes con riesgo elevado?



Thourani VH et al. On behalf of The PARTNER TRIAL Investigators. Five-year Outcomes

from the PARTNER 2A Trial: Transcatheter vs. Surgical Aortic Valve Replacement in

Intermediate-Risk Patients. TCT 2019

PARTNER 2 A


Dager Gómez, A. Ten Approaches for TAVI Access. TCT 2015

TAVI - ACCESOS


Thourani VH et al. On behalf of The PARTNER TRIAL Investigators. Five-year Outcomes

from the PARTNER 2A Trial: Transcatheter vs. Surgical Aortic Valve Replacement in

Intermediate-Risk Patients. TCT 2019

PARTNER 2 A

5.67mm

4.22mm

5.05mm

S.Dcha.S.Izq.

C.Dcha.

PVSecuencial

PV a DA

73 años, masc.,DLP y ex-TBQ. IAM en 1996. CRM y plástica mitral en 2008.

Enf. vasc. Perif. desde 1992,stent en ambas ilíacas primitivas en 2011.

ATC a PV Cx en 2017.Disnea progresiva = Est. Ao. Sev. área =0.7cm2 .

Euro-SCORE II = 18.06% - STS = 13.385%.



73 años, masc.,DLP y ex-TBQ. IAM en 1996. CRM y plástica mitral en 2008.

Enf. vasc. Perif. desde 1992,stent en ambas ilíacas primitivas en 2011.

ATC a PV Cx en 2017.Disnea progresiva = Est. Ao. Sev. área =0.7cm2 .

Euro-SCORE II = 18.06% - STS = 13.385%.

PARTNER 1 PARTNER 2 PARTNER 3

Polyethylene terephthalate (PET)

TAVI. Indicaciones y resultadosEVOLUCIÓN de las Válvulas


Leon MB et al. on behalf of The PARTNER 3 TRIAL Investigators. The Low-Risk TAVR

RCTs DEEP Dive: New Insights from the PARTNER 3 Trial. TCT 2019

PARTNER 3

March 2016 to October 2017


Leon MB et al. on behalf of The PARTNER 3 TRIAL Investigators. The Low-Risk TAVR

RCTs DEEP Dive: New Insights from the PARTNER 3 Trial. TCT 2019

PARTNER 3

PARTNER 3

Mack MJ et al, for the PARTNER 3 Trial Investigators. Transcatheter or Aortic-Valve Replacement

With a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019;380(18):1695-1705.


Core ValveTAVI. Indicaciones y resultados

J Am Coll Cardiol 63:1972-81

N Engl J Med 2017;376:1321-31

N Engl J Med 2019;380:1706-15

https://www.fda.gov/news-events/press-announcements/fda-expands-indication-several-transcatheter-heart-valves-patients-low-risk-death-or-major

August 16, 2019

The U.S. Food and Drug Administration today approved an expanded indication for several

transcatheter heart valves to include patients with severe aortic valve stenosis (a narrowing of the

heart’s aortic valve that restricts blood flow to aorta, the body’s main artery) who are at low risk for

death or major complications associated with open-heart surgery to replace the damaged valves.

These transcatheter valves – Sapien 3, Sapien 3 Ultra, CoreValve Evolut R and CoreValve Evolut

PRO – were previously indicated only for patients at intermediate or higher risk for death or major

complications during open-heart surgery. In low risk patients, open-heart surgery has been the

standard-of-care for aortic valve replacement. However, the procedure to insert a transcatheter heart

valve is less invasive, and involves a smaller incision and shorter recovery time than open-heart

surgery. The FDA is the first medical products regulatory body in the world to expand the indication

for these devices to patients at low risk for death or major complications associated with open-heart

surgery.

TAVI. Indicaciones y resultadosFDA – Aprobación TAVI en Bajo Riesgo

https://www.fda.gov/news-events/press-announcements/fda-expands-indication-several-transcatheter-heart-valves-patients-low-risk-death-or-major


https://doi.org/10.1007/s00392-019-01528-5

Von Scheidt W et al. Interdisciplinary consensus on indications for transfemoral transcatheter

Aortic valve implantation (TF-TAVI). Clinical Research in Cardiology, 13 August 2019.

TAVI. INDICACIONES

https://europepmc.org/abstract/MED/31410547


David TE et al. Hancock II bioprosthesis for aortic valve replacement: the gold standard of

Bioprosthetic valves durability? Ann Thorac Surg 2010; 90: 775-781.

Edad y válvulas biológicas

Baumgartner H et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease.

Eur Heart J 2017;38:2739-2791.

TAVI. Indicaciones y resultadosTAVI vs CIRUGÍA - INDICACIONES

A resolver

Leak Paravalvular

Disturbios de conducción

ACV

Accesos Vasculares

Anticoagulación / Antiagregación

Etc…

Durabilidad

Nuevos dispositivos

Costo/Efectividad

Etc…

Algunas cosas por resolver


Osnabrugge RLJ et al. Costs of Transcatheter Versus Surgical Aortic Valve

Replacement in Intermediate-Risk Patients. Ann Thorac Surg 2012;94:1954–60.

TAVI.CostosTAVI. Indicaciones y resultados

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