Outcomes of Transcatheter Aortic Valve Replacement with Balloon-Expandable Sapien3 Valve in Bicuspid Aortic Stenosis:An analysis of the STS/ACC TVT Registry

Raj R. Makkar*, Sung-Han Yoon, Martin B. Leon, Tarun Chakravarty, Sreekanth

Vemulapalli, Michael Rinaldi, Pinak B. Shah, Eric R. Skipper, Vinod H. Thourani, Vasilis

Babaliaros, Wen Cheng, Alfredo Trento, Samir R. Kapadia, Susheel Kodali, Michael J.

Mack, Gilbert H. L. Tang, Tsuyoshi Kaneko

* Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles

2

• Grant/Research Support

• Consulting Fees/Honoraria

• Major Stock Shareholder/Equity

• Edwards Lifesciences, Abbott Inc., Medtronic, Boston Scientific

• Edwards Lifesciences, Abbott Inc., Medtronic, Boston Scientific

• Entourage Medical

Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement

or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

Raj Makkar, MD

Disclosure Statement

Statistical analyses were performed by Edwards Lifesciences. The views or opinions presented here do not represent

those of the American College of Cardiology, The Society of Thoracic Surgeons, or the STS/ACC TVT Registry.

3

Background & Objective

1 Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation. 2005;111(7):920-925

• Bicuspid aortic valve accounts for up to 50% of patients requiring surgical aortic

valve replacement in the younger population1

• As TAVR becomes a therapeutic option for younger and healthier patients, bicuspid

aortic valves will be seen more often.

• Pivotal clinical trials, including the low risk trials enrolling younger patients, have

excluded patients with bicuspid aortic valves.

• We sought to compare the outcomes of TAVR with balloon-expandable SAPIEN 3

valve in native bicuspid versus tricuspid aortic valve stenosis in the real-world

STS/ACC TVT Registry.

4

Study Population

92236 SAPIEN 3 TAVRs in STS/ACC TVT

Registry(June 2015 − Nov 2018)

552 Sites

79096 Tricuspid ASSAPIEN 3 Patients

7082 N/A, Uncertain, Unicuspid, Quadricuspid

3196 Valve-in-Valve136 Prior TAVR

2726 Bicuspid ASSAPIEN 3 Patients

5

Characteristic% or mean ± SD

Bicuspid AS(n=2726)

Tricuspid AS(n=79096)

p-value

Age (years) 73 ± 11 81 ± 8 <0.0001

STS Risk Score (%) 4.9 ± 4.0 6.5 ± 4.6 <0.0001

Male 60.4 55.1 <0.0001

NYHA III/IV 74.3 75.4 0.20

BMI (kg/m2) 29.2 ± 7.6 29.0 ± 7.3 0.13

Hypertension 84.1 91.2 <0.0001

Diabetes 35.7 38.8 0.001

Peripheral Arterial Disease 24.1 27.6 <0.0001

Carotid Stenosis 14.8 25.2 <0.0001

Atrial Fibrillation 28.8 38.7 <0.0001

Prior Stroke 10.2 11.5 0.04

Chronic Lung Disease 41.5 40.1 0.13

Prior PCI 25.2 34.0 <0.0001

Prior CABG 15.7 20.8 <0.0001

Porcelain Aorta 2.7 3.4 0.05

GFR (mL/min/1.73 m2) 65.3 ± 28.7 59.3 ± 24.5 <0.0001

5MWT (seconds) 7.5 ± 4.2 8.4 ± 5.4 <0.0001

Baseline Characteristics – Unadjusted

6

Study population

25 Covariates used for propensity matching

Age Chronic Lung Disease

Gender (male) Prior PCI

NYHA III/IV Prior CABG

BMI Porcelain Aorta

Hypertension Mean Gradient

Diabetes LVEF

Creatinine ≥ 2 Mitral Regurgitation

Peripheral Arterial

DiseaseTricuspid Regurgitation

Carotid Stenosis 5 Meter Walk Test

Atrial Fibrillation Access Site

Prior Stroke KCCQ

Immunocompromised Hemoglobin

GFR2691 Tricuspid AS

SAPIEN 3 Patients

2691 Bicuspid AS

SAPIEN 3 Patients

79096 Tricuspid AS

SAPIEN 3 Patients

3196 Valve-in-Valve

136 Prior TAVR

7082 N/A, Uncertain,

Unicuspid, Quadricuspid

2726 Bicuspid AS

SAPIEN 3 Patients

1:1 Propensity Matching

92236 SAPIEN 3 Cases in TVT Registry(June 2015 − Nov 2018)

552 Sites

7

Baseline Characteristics – Matched

Characteristic% or mean ± SD

Bicuspid AS(n=2691)

Tricuspid AS(n=2691)

p-value

Age (years) 73 ± 10 73 ± 11 0.47

STS Risk Score (%) 4.9 ± 4.0 5.1 ± 4.2 0.09

Male 60.3 61.5 0.35

NYHA III/IV 74.4 74.1 0.83

BMI (kg/m2) 29.2 ± 7.6 29.4 ± 7.4 0.30

Hypertension 84.5 84.2 0.80

Diabetes 35.8 36.8 0.43

Peripheral Arterial Disease 24.3 24.5 0.90

Carotid Stenosis 15.0 15.6 0.63

Atrial Fibrillation 29.0 29.4 0.73

Prior Stroke 10.2 10.2 0.96

Chronic Lung Disease 41.7 42.0 0.79

Prior PCI 25.5 26.6 0.34

Prior CABG 15.9 17.2 0.18

Porcelain Aorta 2.7 3.1 0.37

GFR (mL/min/1.73 m2) 65.0 ± 28.4 64.4 ± 27.2 0.39

5MWT (seconds) 7.6 ± 4.2 7.6 ± 4.0 0.79

8

Methods

• Primary end-point: Mortality and Stroke at 30-days and 1-year.

• Secondary end-point: Procedural complications, in-hospital adverse events,

post-procedural echocardiographic assessment of the valve, functional status

and health status at 30 days and 1 year.

• To compare death and stroke between bicuspid and tricuspid cohorts, the

patients in the study cohort were linked with Centers for Medicare and Medicaid

Services (CMS) claims data, in addition to the follow-up obtained from the TVT

registry.

9

Baseline Echo

Characteristic% or mean ± SD

Bicuspid AS(n=2691)

Tricuspid AS(n=2691)

p-value

AV Mean Gradient (mmHg) 45.2 ± 15.0 44.9 ± 15.2 0.51

AV Area (cm2) 0.71 ± 0.23 0.71 ± 0.21 0.15

LVEF (%) 53.5 ± 14.7 52.5 ± 15.0 0.02

Annular Size (mm) 25.1 ± 3.2 24.6 ± 3.0 <0.0001

Mitral Regurgitation (mod/sev) (%) 20.6 21.7 0.39

Tricuspid Regurgitation (mod/sev) (%) 14.0 14.1 0.86

10

Characteristic%

Bicuspid AS(n=2691)

Tricuspid AS(n=2691)

p-value

Transfemoral access 93.6 93.9 0.65

Conscious Sedation 42.8 44.1 0.33

Valve Size <0.0001

20mm 2.7 3.1 0.33

23mm 23.0 28.5 <0.0001

26mm 39.1 42.0 0.03

29mm 35.2 26.4 <0.0001

Procedural Data

11

Characteristic% or mean ± SD

Bicuspid AS(n=2691)

Tricuspid AS(n=2691)

p-value

Device success 96.5 96.6 0.87

Procedure Time, min 100.7 ± 51.8 98.2 ± 52.1 0.08

Fluoroscopy Time, min 18.5 ± 11 17.1 ± 10.2 <0.0001

Conversion to open surgery 0.9 0.4 0.03

Annulus Rupture 0.3 0.0 0.02

Cardiopulmonary bypass 1.4 1.0 0.13

Aortic dissection 0.3 0.1 0.34

Coronary Obstruction 0.4 0.3 0.34

Need for a second valve 0.4 0.2 0.16

Procedural Outcomes

12

30-Day Outcomes

KM estimate % Bicuspid Tricuspid AS p-value

All-cause mortality 2.6 2.5 0.82

All stroke 2.4 1.6 0.02

Life-threatening bleeding 0.1 0.1 0.99

Major vascular complication 0.9 1.0 0.68

New pacemaker 9.1 7.5 0.03

Aortic valve reintervention 0.2 0.3 0.79

13

1-year Mortality and All Stroke Unadjusted Cohort

Log rank P < 0.001

HR: 0.75 [95% CI: 0.65, 0.87]

All-C

au

se M

ort

ality

(%)

0

5

10

15

20

25

30

35

40

Time in Months

0 3 6 9 12

10.4%

14.4%

Bicuspid

Tricuspid

2726 1272 1235 1175 947

79096 41830 40133 37794 30309

Number at risk

2726 1247 1209 1148 923

79096 41050 39266 36851 29459

P = 0.721

HR: 1.04 [95% CI: 0.83, 1.31]

3.4%

3.7%

Str

oke (

%)

Bicuspid

Tricuspid

0

5

10

15

20

25

30

35

40

Time in Months0 3 6 9 12

Number at risk

Bicuspid

Tricuspid

Bicuspid

Tricuspid

14

Bicuspid

Tricuspid

1-Year Mortality – Matched

2691 1259 1222 1162 934

2691 1367 1326 1256 977

P= 0.31HR: 0.90 [95% CI: 0.73, 1.10]

10.5%

12.0%

All-C

au

se M

ort

ality

(%

)

0

5

10

15

20

25

30

35

40

Time in Months

0 3 6 9 12

Bicuspid

Tricuspid

Number at risk

15

Bicuspid

Tricuspid

1-Year Stroke – Matched

2691 1234 1196 1135 910

2691 1341 1296 1226 952

P= 0.16HR: 1.28 [95% CI: 0.91, 1.79]

3.1%

3.4%

Str

oke (

%)

Time in Months

0 3 6 9 12

Bicuspid

Tricuspid

Number at risk

0

5

10

15

20

25

30

35

40

16

Bicuspid

Tricuspid

1-Year Mortality or Stroke – Matched

2691 1234 1196 1135 910

2691 1341 1296 1226 952

P= 0.75HR: 0.97 [95% CI: 0.81, 1.16]

12.9%

14.1%

Mo

rtality

or

Str

oke (

%)

Time in Months

0 3 6 9 12

Bicuspid

Tricuspid

Number at risk

0

5

10

15

20

25

30

35

40

17

Timing of All-Stroke Events

0%

10%

20%

30%

40%

50%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Bicuspid (N=63)

Tricuspid (N=41)

P-value=0.54

18

Paravalvular Leak – Matched

81.5% 83.7%74.4% 77.2% 75.7% 78.8%

17.0% 15.5%23.6% 20.5% 21.1% 18.7%

1.3% 0.7% 2.0% 2.3% 3.0% 2.5%

0.1% 0.1% 0.1% 0.1% 0.2% 0.0%

0%

20%

40%

60%

80%

100%

Bicuspid(n=2179)

Tricuspid(n=2233)

Bicuspid(n=1711)

Tricuspid(n=1782)

Biscuspid(n=593)

Tricuspid(n=673)

Severe

Moderate

Mild

None/Trace

Discharge 30-day 1-year

p=0.44p=0.17p=0.08

19

0

15

30

45

60

Baseline Discharge 30-day 1-year

Me

an

Gra

die

nt

(mm

Hg

)

Mean Gradient

Bicuspid Tricuspid

p=0.69

Hemodynamics – Matched

p=0.15 p=0.86p=0.51

0

0.5

1

1.5

2

2.5

3

Baseline Discharge

AV

A (

cm

2)

Aortic Valve AreaBicuspid Tricuspid

p=0.15 p=0.34

20

3.4% 3.5%

54.9% 54.7% 59.7% 60.8%

22.2% 22.4%

38.4% 37.7% 32.3% 32.7%

59.9% 60.3%

6.3% 6.9% 6.8% 5.3%14.4% 13.8%

0.5% 0.6% 1.2% 1.1%

0%

20%

40%

60%

80%

100%

Bicuspid(n=2667)

Tricuspid(n=2664)

Bicuspid(n=1958)

Tricuspid(n=2015)

Biscuspid(n=752)

Tricuspid(n=804)

IV

III

II

I

NYHA Class – Matched

Baseline 30-day 1-year

p=0.93 p=0.80 p=0.70

21

0

20

40

60

80

100

120

Baseline 30-day 1-year

KC

CQ

Ove

rall

Su

mm

ary

S

co

re

Bicuspid

Tricuspid

KCCQ – Matched

p=0.87 p=0.52 p=0.15

n=2460 n=2463 n=1992 n=1990 n=732 n=776

22

Limitations

• Lack of center-independent adjudication of adverse events as well as potential under-reporting of adverse events.

• Bicuspid AS represents a heterogeneous anatomic cohort, It is possible that the operators selected the most favorable anatomic subsets while excluding patients with highest risk anatomical features

• Lack of a control group of bicuspid AS patients treated surgically

• Impact of aortopathy on outcomes could not be assessed

23

Summary

• In this largest real life registry of all consecutive TAVRs in the US, TAVR with balloon expandable Sapien 3 valve for Bicuspid AS, compared to tricuspid AS, was associated with

• Similar survival at 30 days and 1 year

• Increased risk of aortic root injury and conversion to open heart surgery; although overall rate was still low (<1.0%).

• Increased peri-procedural and 30 day stroke rates

• Equivalent hemodynamics (Similar and significant reduction in transaortic gradients, improvement in aortic valve areas and frequency of paravalvular leak rates)

• Similar improvement in Quality of Life metrics (NYHA class and KCCQ scores)

24

Clinical Implications

• This analysis suggests that select bicuspid anatomy is amenable to TAVR with current generation balloon-expandable TAVR technology with acceptable clinical outcomes.

• These data provide an argument for TAVR to be a reasonable alternative for bicuspid AS in patients who are intermediate or high risk for surgical aortic valve replacement and provide a sound basis to conduct a randomized clinical trial in young patients with bicuspid AS who are low risk for surgery.