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Trans-apical Transcatheter Aortic Valve Replacement in a Patient with Severe and Complex Left Main Coronary Artery Disease (LMCAD)

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Cardiac & Vascular Repair Tools Subsegment, Cardiac and Cardiovascular Surgical Procedures, Medical Imaging Technology, Image Processing/Computing, MRI, CT, Nuclear Medicine, Ultra Sound, PCI, Stents & Tools, Technology Transfer: Biotech and Pharmaceutical, Uncategorized, Valves & Tools, tagged Angina pectoris, Aortic valve, Aortic valve replacement, CABG, Cardiovascular disease, Columbia University Medical Center, Coronary artery bypass surgery, Coronary artery disease, Edwards Lifesciences Corporation, Food and Drug Administration, Percutaneous coronary intervention, surgery, TAVR on June 17, 2013| 12 Comments »

Trans-apical Transcatheter Aortic Valve Replacement in a Patient with Severe and Complex Left Main Coronary Artery Disease (LMCAD)

Writer: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN

Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease (LMCAD) is found in 4 to 6 percent of all patients who undergo coronary arteriography [1]. When present, it is associated with multivessel coronary artery disease (MVCAD) about 70 percent of the time [2,3].

Most patients are symptomatic and at high risk of cardiovascular events, since occlusion of this vessel compromises flow to at least 75 percent of the left ventricle, unless it is protected by collateral flow or a patent bypass graft to either the left anterior descending or circumflex artery. Studies performed before revascularization with coronary artery bypass graft surgery (CABG) became the standard of care revealed a poor prognosis for these patients, with three-year survival as low as 37 percent [4]. CABG, when directly compared to medical therapy, is associated with significantly better cardiovascular outcomes, including mortality [5].

Percutaneous coronary intervention (PCI) with stenting has generally been restricted to such patients considered inoperable or at high risk for CABG, or with prior CABG and at least one patent graft to the left anterior descending or circumflex artery (so-called “protected” left main disease). Graft patency is important in this setting in the event of acute or late closure after PCI. However, evidence is increasing to support the use of PCI with stenting in some cases. (See ‘PCI versus CABG’ below.)

Asymptomatic patients with left main lesions felt to not be hemodynamically significant should be managed with preventative therapies. Patients with anginal symptoms attributable to lesions elsewhere should be managed with therapies similar to those used in other patients with coronary artery disease. (See “Overview of the care of patients with stable ischemic heart disease”.)

This topic will discuss most aspects of the management of patients with LMCAD. The approach to patients with multivessel coronary artery disease without LMCAD is discussed elsewhere. (See “Bypass surgery versus percutaneous intervention in the management of stable angina pectoris: Recommendations”.)

http://www.uptodate.com/contents/management-of-left-main-coronary-artery-disease

Catheter Cardiovasc Interv. 2013 Feb 14.

http://dx.doi.org/10.1002/ccd.24865. [Epub ahead of print]

Management of significant left main coronary disease before and after trans-apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease.

Paradis JM, George I, Kodali S.

Source

Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.

Abstract

We report the case of an 81-year-old woman with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease who underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans-apical transcatheter aortic valve replacement performed with a transfemoral device. After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. © 2013 Wiley Periodicals, Inc.

PMID: 23413172

Transapical deployment of an Aortic Valve

WATCH VIDEO

Investigational Devices: Edwards Sapien Transcatheter Aortic Valve Transapical Deployment

This is an interesting surgical case presented by the Columbia University Cardiovascular Surgery team, illustrating the importance of combined team skills in the most difficult of cases. It is part of a series on cardiovascular surgery.

Management of significant left main coronary disease before and after trans-apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease.

Paradis JM, George I, and Kodali S

Catheterization and Cardiovascular Interventions (2013)

http://dx.doi.org/10.1002/ccd.24865

Introduction

Transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN transcatheter heart valve (THV) (Edwards Lifesciences, Irvin, CA) has been shown to reduce mortality when compared to medical therapy alone for patients with symptomatic severe aortic stenosis deemed unsuitable for surgical aortic valve replacement due to multiple co-morbidities. The Edwards SAPIEN THV, sizes 23 and 26 mm, and the RetroFlex 3 transfemoral delivery system, have been recently approved by the US Food and Drug Administration (FDA) for commercial use outside of the PARTNER clinical trial for patients considered inoperable. However, an alternative site needs to be selected for patients with peripheral arteries inadequate for transfemoral TAVR. Although not fully validated, the transapical approach or the transaortic route using a balloon expandable THV, appears to be appropriate for this specific purpose. Significant coronary artery disease (CAD) is often found in patients with severe aortic stenosis. in > 50% of patients with aortic stenosis over 70 years of age and in > 65% of patients who are over 80 years of age. There is no established guideline for managing significant CAD in the context of TAVR, including the appropriate revascularization strategy as well as the timing of interventions.

Case Report

An 81-year-old woman presented with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease. She had a six-month history prior to admission of progressive exertional shortness of breath and fatigue, and a long history fo hypertension, hyperlipidemia, obesity, and severe peripheral vascular disease. In 2003, she underwent a coronary artery bypass graft (CABG) surgery, with grafting of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, a saphenous vein graft (SVG) to the first obtuse marginal (OM) branch, and a SVG to the right coronary artery (RCA). Due to associated severe mitral regurgitation, a mitral valve ring annuloplasty was also performed. A transthoracic echocardiogram (TTE) revealed severe aortic stenosis with a peak gradient across the aortic valve of 63 mm Hg, a mean gradient of 39 mm Hg, and an aortic valve area of 0.8 cm2. The left ventricular ejection fraction (LVEF) was 64% while the pulmonary artery systolic pressure was measured at 28 mm Hg. Extreme calcification and tortuosity precluded the advancement of any wire, catheter, or sheath, contributing to two attempts at cardiac catheterization prior to transfer with a total occlusion of the distal abdominal aorta, at the level of the aorto-iliac bifurcation, and the left main, proximal LAD, proximal left circumflex, and the proximal RCA all had greater than 70% coronary lesions. In addition, ostial total occlusions were seen in both SVGs.

After transfer, a cardiac catheterization through the right radial artery was attempted without success due to calcification and tortuosity in the arterial bed. An 80% distal left main lesion was clearly identified with a Judkins left 3.5 guiding catheter. There was non-flow limiting coronary disease in the left circumflex and competitive retrograde flow seen in the LIMA graft, but they still were unable to cannulate the RCA and the SVGs. It was determined that the patient was inoperable, on grounds of her significant frailty, reoperative status and overall comorbid state (Society of Thoracic Surgeons (STS) risk score of 11%). Furthermore, due to the occlusion of the distal aorta, the patient was unsuitable for a TAVR via the transfemoral approach.

They chose to approach her PCI via a conduit on the right axillary artery and perform a concomitant TAVR from a trans-apical approach due to the serious limiting condition of the patient. She underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans-apical transcatheter aortic valve replacement performed with a transfemoral device. Excellent flow from the conduit was noted. A 7 French (Fr) sheath was connected to the end of the conduit, which was kept long to allow better maneuverability (Fig. 1). A Rosen wire was passed with some difficulty to the aortic root, and was switched to a stiff wire in an attempt to straighten the vessel.

Fig. 1. Transaxillary conduit used during the procedure. A 7 French sheath was connected to an 8 mm dacron graft, which was previously sewn to the axillary artery.

After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. A Xience

V everolimus eluting stent 3.5 mm 18 mm was implanted starting 2 mm distal to the ostium of the left main, extending in the proximal portion of the left circumflex artery. After one post-dilatation with a non-compliant balloon, the final angiographic result was excellent.

They used a Retroflex 3 transfemoral delivery sheath to perform the trans-apical TAVR. They estimated the size and length of the ventricular cavity, and then placed markers on the delivery sheath (prior to insertion) indicating the appropriate length of sheath to remain outside the heart (Fig. 2).

Fig. 2. Marker placed on the RetroFlex 3 transfemoral sheath to safely guide its insertion inside the left ventricular cavity during the trans-apical transcatheter aortic valve replacement.

A 23 mm Edwards SAPIEN valve was selected and deployed under fluoroscopic and transesophageal echocardiographic guidance. Immediately after deployment, turbulent flow was noted within the left main with the color Doppler on TEE, indicating a new obstruction of the left main, which a left coronary angiogram showed to be a severe proximal lesion. Through the trans-axillary conduit, a guiding catheter was laboriously brought in the ascending aorta and cannulated the left main artery which permitted a predilation and a stent insertion in the ostial portion of the left main. She was discharged to a rehabilitation facility 7 days after the procedure.

On follow-up TTE, the LVEF was 55% without any significant wall motion abnormality. There was no aortic regurgitation, and the peak and mean gradients were 14.9 mm Hg and 8.0 mm Hg, respectively. The patient is still doing well more than 6 months after the procedure. She is now in NYHA class 2 and has not had any recurrent hospitalization for congestive heart failure.

Discussion

This report is a case of a complex percutaneous coronary intervention of the left main coronary artery via a right axillary conduit followed immediately by an off label commercial transapical TAVR using the Retro-Flex 3 trans-femoral introducer sheath, complicated finally by a new left main coronary obstruction mandating another PCI. It is the first description of a TAVR procedure preceded and followed by a left main trans-axillary PCI. The role of TEE (color Doppler) in the diagnosis of a very rare TAVR complication is also noteworthy. In a recent meta-analysis of 3,519 patients from 16 studies using the Valve Academic Research Consortium (VARC) definitions, the pooled estimate rate of coronary

obstruction following TAVR was only 0.7%. Obviously, the early recognition and treatment of this hazard is imperative.

The surgical management of this patient also warrants discussion. The hybrid surgical approach of accessing the axillary artery via a conduit provides numerous advantages:

(1) the ascending aorta, coronaries, and aortic valve are easily accessible;

(2) transition to cardiopulmonary bypass or extra-corporeal membrane oxygenation, if needed, is quick; and

(3) long-term morbidity is minimal for the patient when compared to aorto-iliac, aortic, or femoral conduits.

Finally, the heart team approach not only allowed the realization of a difficult coronary

stent implantation through an unusual transaxillary graft followed by a transapical TAVR in a patient with significant peripheral arterial disease, but also permitted the early recognition and management of a potentially fatal left main obstruction. Considerations such as team-based care, close communication between the different specialties

involved and careful planning for outlining management of potential complications are therefore essential for the success of a TAVR program.

REFERENCES

1. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597–1607.

2. Iung B. Interface between valve disease and ischaemic heart disease. Heart 2000;84:347–352.

3. Wenaweser P, Pilgrim T, Guerios E, Stortecky S, Huber C, Khattab AA, et al. Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation.

EuroIntervention 2011;7:541–548.

4. Genereux P, Head SJ, Van Mieghem NM, Kodali S, Kirtane AJ, Xu K, et al. Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: A weighted meta-analysis of 3,519 patients from 16 studies.

J Am Coll Cardiol 2012;59:2317–2326.

Postdilatation to Reduce Paravalvular Regurgitation During Transcatheter Aortic Valve Replacement (pharmaceuticalintelligence.com)
No Early Symptoms – An Aortic Aneurysm Before It Ruptures – Is There A Way To Know If I Have it? (pharmaceuticalintelligence.com)
TAVR for Aortic Regurgitation: Proceed with Caution (zedie.wordpress.com)
How to Get a Minimally Invasive Aortic Valve Replacement (tavrvalvereplacement.wordpress.com)
Medtronic CoreValve EU Cleared for Transcatheter Valve-In-Valve Procedures (medgadget.com)
Aortic stenosis?!! (myheartnet.wordpress.com)

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. (Photo credit: Wikipedia)

heart with coronary arteries (Photo credit: Wikipedia)

Micrograph of an artery that supplies the heart with significant atherosclerosis and marked luminal narrowing. Tissue has been stained using Masson’s trichrome. (Photo credit: Wikipedia)

Transcatheter Aortic Valve Replacement (TAVR): Postdilatation to Reduce Paravalvular Regurgitation During TAVR with a Balloon-expandable Valve

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Cardiac & Vascular Repair Tools Subsegment, Cardiac and Cardiovascular Surgical Procedures, Frontiers in Cardiology and Cardiovascular Disorders, Valves & Tools, tagged Aortic insufficiency, Aortic valve, Aortic valve replacement, Columbia University, Columbia University Medical Center, Doctor of Philosophy, Edwards Lifescience, surgery, TAVR on June 17, 2013| 8 Comments »

Transcatheter Aortic Valve Replacement (TAVR): Postdilatation to Reduce Paravalvular Regurgitation During TAVR with a Balloon-expandable Valve

Reviewer: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN

This report is one in a series on advances in cardiovascular surgery. This report particularly focuses on the safety and efficacy of transcatheter aortic valve replacement (TAVR), a major study carried out at Columbia University Medical Center, involving reduction of paravalvular regurgitation post TAVI.

Circ Cardiovasc Interv. 2013 Feb;6(1):85-91. doi: 10.1161/CIRCINTERVENTIONS.112.971614. Epub 2013 Jan 22.

Efficacy and safety of postdilatation to reduce paravalvular regurgitation during balloon-expandable transcatheter aortic valve replacement.

Daneault B, Koss E, Hahn RT, Kodali S, Williams MR, Généreux P, Paradis JM, George I, Reiss GR, Moses JW, Smith CR, Leon MB.

Source

Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY 10032, USA.

Abstract

BACKGROUND:

Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) and may be associated with adverse outcomes. Postdilatation (PD) has been proposed to treat PVR without being formally studied. We performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR.

METHODS AND RESULTS:

Consecutive cases of TAVR were reviewed for clinical outcomes. Procedural transesophageal echocardiography imaging was reviewed for a subgroup of consecutive patients. PVR areas seen on a short-axis view were measured immediately after deployment, after PD, and at the completion of the study. Stent dimensions measured using angiography and the Paieon’s C-THV system pre- and post-PD were compared. Between May 2007 and November 2011, 259 patients underwent TAVR at our institution. PD was performed in 106 patients (41%). These patients had larger annulus, lower cover-index; more often had transfemoral access and implantation of a 26 mm valve. There was a nonsignificant greater rate of cerebrovascular events in PD patients. There was no significant difference in major aortic injury and permanent pacemaker implantation rates between groups. TTE studies were reviewed in 58 patients (35 with PD and 23 without PD). PD patients had larger PVR areas immediately after deployment (40.3±17.1 versus 15.4±14.2 mm(2); P<0.0001). There was significant reduction in PVR area attributable to PD (21.7±9.3 mm(2); P<0.0001). Spontaneous regression of PVR was seen in both groups. PD increased stent dimensions.

CONCLUSIONS:

This study demonstrates the efficacy of PD at reducing PVR in patients with greater than mild PVR after balloon-expandable TAVR.

PMID: 23339841

Efficacy and Safety of Postdilatation to Reduce Paravalvular Regurgitation During Balloon-Expandable Transcatheter Aortic Valve Replacement

Daneault R, Koss E, Hahn RT, Kodali S, Williams MR, et al.
Circ Cardiovasc Interv. 2013;6:85-91. http://dx.doi.org/10.1161/circinterventions.112.971614

Transcatheter aortic valve replacement (TAVR) has emerged as a new alternative treatment for patients with severe aortic stenosis, who are at high risk or deemed inadequate candidates for conventional surgical aortic valve replacement. Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) reported in 80% to 96% of TAVR cases Moreover, moderate and severe degrees of regurgitation are associated with worse clinical outcomes While the risk factors are known and include: smaller cover index, annulus eccentricity, and the degree and distribution of leaflet calcifications, postdilatation (PD) of balloon expandable valves after implantation, including transcatheter heart valve (THV) traumatic aorta injury, cerebrovascular embolus, and conduction block may outweigh the potential benefits from reduction in aortic regurgitation. Therefore, these investigators performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR.

What Is Known

• Significant paravalvular regurgitation after transcatheter aortic valve replacement is associatedwith increased mortality.
• Calcifications, undersized prosthesis, and malposition are causes of paravalvular regurgitation.

Study Design

Procedural and in-hospital outcomes for all consecutive patients treated between May 2007 and November 2011 with Edwards SAPIEN THV (Edwards Lifescience, Irvine, CA) as part of the PARTNER and PARTNER 2 trials were reviewed both prospectively and retrospectively. Information on PD was collected retrospectively from chart and imaging review for the period between 2007 and August 2010, and prospectively after August 2010. PD was performed in cases where PVR was qualitatively more than mild, by transesophageal echocardiography (TEE), immediately after THV implantation. There were 259 patients who underwent TAVR. PD was performed in 106 patients (41%). Procedural transesophageal echocardiography imaging was reviewed for a subgroup of consecutive patients. PVR areas seen on a short-axis view were measured immediately after deployment, after PD, and at the completion of the study. Stent dimensions measured using angiography and the Paieon’s C-THV system pre- and post-PD were compared, and TTE studies were reviewed in 58 patients (35 with PD and 23 without PD).

Endpoints

Neurological events were defined using valve academic research consortium definitions.14 Cover-index is defined as: 100×([THV diameter–TEE annulus diameter]/THV diameter).3 Clinical end points for the current analysis included 30-day mortality, in-hospital stroke or transient ischemic attack, procedural related major aortic injury (aortic dissection, aortic wall hematoma, or annulus/aortic rupture) and need for new permanent pacemaker during the index hospitalization. Echocardiographic end points included spontaneous reduction of PVR [difference between PVR1 and PVR3 in the non-PD group (PD−) and difference between PVR2 and PVR3 in the PD group (PD+)], and reduction of PVR attributable to PD
(PVR1−PVR2) in the PD+. Angiographic end points included additional expansion of IF, OF, and minimal diameters of stents after PD.

Results and Clinical Outcomes

No valve embolization occurred during PD. No patient required implantation of a second THV after PD. Multiple PD was performed in 4 cases. There was no statistically significant
difference between the 2 groups in the incidence of neurological events, although they were more frequent in patients with PD. Permanent pacemaker implantation during the index hospitalization was not significantly different between the 2 groups. Major aortic injuries were rare and occurred at a similar rate between both groups with no aortic annulus rupture in either group.

These (PD) patients had larger annulus, lower cover-index; more often had transfemoral access and implantation of a 26 mm valve. There was a nonsignificant greater rate of cerebrovascular events in PD patients. There was no significant difference in major aortic injury and permanent pacemaker implantation rates between groups.
PD patients had larger PVR areas immediately after deployment (40.3±17.1 versus 15.4±14.2 mm2; P<0.0001). There was significant reduction in PVR area attributable to PD (21.7±9.3 mm2; P<0.0001). Spontaneous regression of PVR was seen in both groups.
PD increased stent dimensions. There was a significant increase in the OF, IF, and minimal diameters after PD of 26 mm valves. The changes were not statistically significant for the 23 mm valves. There was a greater expansion in the IF and OF diameters compared with the minimal diameter.

Discussion

This study is the second that demonstrates the efficacy of PD at reducing postdeployment PVR in patients with greater than mild PVR after balloon-expandable TAVR. Moreover, judicious use of PD for greater than mild PVR is not associated with excess morbidity or mortality, although some concerns regarding cerebral embolism deserve comment. When it occurs, PVR is a significant cause of nonstructural prosthetic valve dysfunction. The anatomic positioning and resultant physiology of THV, however, are different from surgical valves. After surgical aortic valve replacement, most commonly PVR is attributable to infection, suture dehiscence, or fibrosis and calcification of the native annulus, resulting in inadequate contact or gaps between the sewing ring and annulus. Because THVs do not have a sewing ring traditional dehiscence cannot occur. For balloon-expandable THV, significant PVR most commonly results from incomplete prosthesis apposition to the native annulus.

What the Study Adds

• Additional postdilatation can reduce the magnitude of paravalvular regurgitation.
• Spontaneous regression of paravalvular regurgitation occurs within minutes after transcatheter aortic valve replacement.
• Postdilatation may be associated with increased risk of cerebrovascular events.

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Direct Flow Medical Wins European Clearance for Catheter Delivered Aortic Valve

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Cardiac & Vascular Repair Tools Subsegment, Ecosystems & Industrial Concentration in the Medical Device Sector, FDA Regulatory Affairs, FDA, CE Mark & Global Regulatory Affairs: process management and strategic planning - GCP, GLP, ISO 14155, Frontiers in Cardiology and Cardiovascular Disorders, Medical Devices R&D and Inventions, Medical Devices R&D Investment, Medical Imaging Technology, Image Processing/Computing, MRI, CT, Nuclear Medicine, Ultra Sound, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Valves & Tools, tagged Aortic valve, Catheter, CE mark, Direct Flow Medical, Inflatable on January 29, 2013| 6 Comments »

Direct Flow Medical Wins European Clearance for Catheter Delivered Aortic Valve

Reporter: Aviva Lev-Ari, PhD, RN

UPDATED on 7/15/2018

Direct Flow Medical, which markets a CE-marked transcatheter aortic valve implantation (TAVI) device, has closed after funding from a Chinese pharmaceutical company did not come through. According to newspaper The Press Democrat, all 250 company’s employees have been made redundant and it officially ceased trading on 30 November.

The paper reports that Direct Flow’s former president and chief executive officer Dan Lemaitre, in a phone interview, told them the company had expected an influx of funding from a Chinese pharmaceutical company on 18 November but the deal collapsed two days before the money was scheduled to arrive. Lemaitre said this was because “the terms of which were changed dramatically in a very unacceptable fashion.”

The Press Democrat claims that the 12-year-old company had no other options and its lender—PDL BioPharma Inc—refused to extend the US$65 million funding arrangement it had with Direct Flow for the past three years and foreclosed upon the business.

SOURCE

https://cardiovascularnews.com/tavi-company-direct-flow-medical-closes-after-failing-to-secure-funding/

TAVI company Direct Flow Medical closes after failing to secure funding

16th January 2017

Catheter Delivered Aortic Valve from Direct Flow Medical Wins European Clearance (w/video)

by GENE OSTROVSKY on Jan 28, 2013 • 1:32 pm

Having unveiled attractive results of a study on its transcatheter aortic valve, Direct Flow Medical (Santa Rosa, CA) has just announced CE Mark approval for the device. The polymer frame prosthesis sits on top of the diseased natural valve with its inflatable rings guaranteeing contact along the perimeter.

Direct Flow Medical v Catheter Delivered Aortic Valve from Direct Flow Medical Wins European Clearance (w/video)

Since the new valve only uses physical pressure from the inflatable rings to hold on, it can be repositioned at any time or removed completely if necessary.

Here’s more about the valve from its product page:

The bovine pericardial leaflets are attached to an inflatable polyester fabric cuff which conforms to the native aortic valve annulus and left ventricular outflow tract to form a seal to minimize the potential of paravalvular leak. The Bioprosthesis is designed with independently inflatable ventricular and aortic rings, which encircle and capture the native valve annulus to provide positive axial anchoring of the device. Inflation of the cuff with a saline and contrast solution renders the valve immediately functional and permits fluoroscopic visualization. Before final deployment, the saline and contrast mixture is exchanged under pressure, maintaining cuff shape and position, with a solidifying Polymer that hardens to form the permanent support structure.

WATCH VIDEO

Direct Flow Medical: Transcatheter Aortic Valve

Flashback: Direct Flow Medical Transcatheter Aortic Valve Does Well in Clinical Study

Product page: Direct Flow Medical Transcatheter Aortic Valve System…

SOURCE:

http://www.medgadget.com/2013/01/catheter-delivered-aortic-valve-from-direct-flow-medical-wins-european-clearance-wvideo.html?

http://www.medgadget.com/2013/01/catheter-delivered-aortic-valve-from-direct-flow-medical-wins-european-clearance-wvideo.html?goback=%2Egde_4346921_member_205701983%2Egmr_675087%2Eanp_675087_1359500095698_1%2Egmr_675087%2Egde_675087_member_208816811%2Egmr_675087

Artherogenesis: Predictor of CVD – the Smaller and Denser LDL Particles

Posted in Bio Instrumentation in Experimental Life Sciences Research, Biomarkers & Medical Diagnostics, Cell Biology, Signaling & Cell Circuits, Chemical Biology and its relations to Metabolic Disease, Disease Biology, Small Molecules in Development of Therapeutic Drugs, FDA Regulatory Affairs, Frontiers in Cardiology and Cardiovascular Disorders, HTN, Liver & Digestive Diseases Research, Metabolomics, Origins of Cardiovascular Disease, Pharmaceutical Analytics, Pharmaceutical Industry Competitive Intelligence, Pharmacotherapy of Cardiovascular Disease, Population Health Management, Genetics & Pharmaceutical, Population Health Management, Nutrition and Phytochemistry, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Statistical Methods for Research Evaluation, Systemic Inflammatory Response Related Disorders, Technology Transfer: Biotech and Pharmaceutical, tagged Aortic valve, Aortic valve stenosis, Blood Institute, Heart disease, High-density lipoprotein, Journal of the American College of Cardiology, Lipoprotein, Low-density lipoprotein, LPA, National Heart Lung and Blood Institute, New England Journal of Medicine, Single-nucleotide polymorphism on November 15, 2012| 10 Comments »

Artherogenesis: Predictor of CVD – the Smaller and Denser LDL Particles

Reporter: Aviva Lev-Ari, PhD, RN

Updated 3/5/2013

Genetic Associations with Valvular Calcification and Aortic Stenosis

N Engl J Med 2013; 368:503-512

February 7, 2013DOI: 10.1056/NEJMoa1109034

METHODS

We determined genomewide associations with the presence of aortic-valve calcification (among 6942 participants) and mitral annular calcification (among 3795 participants), as detected by computed tomographic (CT) scanning; the study population for this analysis included persons of white European ancestry from three cohorts participating in the Cohorts for Heart and Aging Research in Genomic Epidemiology consortium (discovery population). Findings were replicated in independent cohorts of persons with either CT-detected valvular calcification or clinical aortic stenosis.

CONCLUSIONS

Genetic variation in the LPA locus, mediated by Lp(a) levels, is associated with aortic-valve calcification across multiple ethnic groups and with incident clinical aortic stenosis. (Funded by the National Heart, Lung, and Blood Institute and others.)

SOURCE:

N Engl J Med 2013; 368:503-512

HDL is more than an eNOS Agonist

In addition to the modulation of NO production by signaling events that rapidly dictate the level of enzymatic activity, important control of eNOS involves changes in the abundance of the enzyme. In a clinical trial by the Karas laboratory of niacin therapy in patients with low HDL levels (nine males and two females), flow-mediated dilation of the brachial artery was improved in association with a rise in HDL of 33% over 3 months (Kuvin et al., 2002).

Am. Heart J., 144:165–172.

They also demonstrated that eNOS expression in cultured human endothelial cells is increased by HDL exposure for 24 hours. They further showed that the increase in eNOS is related to an increase in the half-life of the protein, and that this is mediated by PI3K–Akt kinase and MAPK (Ramet et al., 2003).

J. Am. Coll. Cardiol., 41:2288–2297.

Thus, the same mechanisms that underlie the acute activation of eNOS by HDL appear to be operative in upregulating the expression of the enzyme.

The current understanding of the mechanism by which HDL enhances endothelial NO production is summarized in Shaul & Mineo (2004), Figure 1.

J Clin Invest., 15; 113(4): 509–513.

It describes the mechanism of action for HDL enhancement of NO production by eNOS in vascular endothelium.

(a) HDL causes membrane-initiated signaling, which stimulates eNOS activity. The eNOS protein is localized in cholesterol-enriched (orange circles) plasma membrane caveolae as a result of the myristoylation and palmitoylation of the protein. Binding of HDL to SR-BI via apoAI causes rapid activation of the nonreceptor tyrosine kinase src, leading to PI3K activation and downstream activation of Akt kinase and MAPK. Akt enhances eNOS activity by phosphorylation, and independent MAPK-mediated processes are additionally required (Duarte, et al., 1997). Eur J Pharmacol, 338:25–33.

HDL also causes an increase in intracellular Ca²⁺ concentration (intracellular Ca²⁺ store shown in blue; Ca²⁺ channel shown in pink), which enhances binding of calmodulin (CM) to eNOS. HDL-induced signaling is mediated at least partially by the HDL-associated lysophospholipids SPC, S1P, and LSF acting through the G protein–coupled lysophospholipid receptor S1P3. HDL-associated estradiol (E2) may also activate signaling by binding to plasma membrane–associated estrogen receptors (ERs), which are also G protein coupled. It remains to be determined if signaling events are also directly mediated by SR-BI (Yuhanna et al., 2001), (Nofer et al., 2004), (Gong et al., 2003), (Mineo et al., 2003).

Nat. Med., 7:853–857.

J. Clin. Invest.,113:569–581.

J. Clin. Invest., 111:1579–1587.

J. Biol. Chem., 278:9142–9149.

(b) HDL regulates eNOS abundance and subcellular distribution. In addition to modulating the acute response, the activation of the PI3K–Akt kinase pathway and MAPK by HDL upregulates eNOS expression (open arrows). HDL also regulates the lipid environment in caveolae (dashed arrows). Oxidized LDL (OxLDL) can serve as a cholesterol acceptor (orange circles), thereby disrupting caveolae and eNOS function. However, in the presence of OxLDL, HDL maintains the total cholesterol content of caveolae by the provision of cholesterol ester (blue circles), resulting in preservation of the eNOS signaling module (Ramet et al., 2003), (Blair et al., 1999), (Uittenbogaard et al., 2000).

J. Am. Coll. Cardiol., 41:2288–2297.

J. Biol. Chem., 274:32512–32519.

J. Biol. Chem., 275:11278–11283.

SOURCE:

Shaul, PW and Mineo, C, (2004). HDL action on the vascular wall: is the answer NO? J Clin Invest., 15; 113(4): 509–513.

Are Additional Lipid Measures Useful?

Ryan D. Bradley, ND; and Erica B. Oberg, ND, MPH

http://www.imjournal.com/resources/web_pdfs/recent/1208_bradley.pdf

Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) are the well-established standards by which clinicians identify individuals at risk for coronary artery disease (CAD), yet nearly 50% of people who have a myocardial infarction have normal cholesterol levels. Measurement of additional biomarkers may be useful to more fully stratify patients according to disease risk. The typical lipid panel includes TC, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs). Emerging biomarkers for cardiovascular risk include measures of LDL-C pattern, size, and density; LDL particle number; lipoprotein(a); apolipoproteins (apoA1 and apoB100 being the most useful); C-reactive protein; and lipoprotein-associated phospholipase

Some of these emerging biomarkers have been proven to add to, or be more accurate than, traditional risk factors in predicting coronary artery disease and, thus, may be useful for clinical decision-making in high-risk patients and in patients with borderline traditional risk factors. However, we still believe that until treatment strategies can uniquely address these added risk factors—ie, until protocols to rectify unhealthy findings are shown to improve cardiovascular outcomes—healthcare providers should continue to focus primarily on helping patients reach optimal LDL-C, HDL-C, and TG levels

Table 1. Traditional Lipid Panel and Recommended Treatment

Goals for Cardiovascular Disease Prevention34

Total Cholesterol Desirable (low) < 200 mg/dL
Borderline high 200-239 mg/dL
High 240 mg/dL or greater
HDL Cholesterol Desirable (high) > 60 mg/dL
Acceptable 40-60 mg/dL
Low < 40 mg/dL
LDL Cholesterol Desirable (low) < 100 mg/dL
Acceptable 100-129 mg/dL
Borderline high 130-159 mg/dL
High 160-189 mg/dL
Very high 190 mg/dL or greater
Triglycerides Desirable (low) < 150 mg/dL
Borderline high 150-199 mg/dL
High 200-499 mg/dL
Very high 500 mg/dL or greater

LDL-C and HDL-C: Pattern, Size, and Density

Two patterns predominate and are used to describe the average size of LDL particles. Pattern A refers to a preponderance of large LDL particles, while Pattern B refers to a preponderance of small LDL particles; a minority of individuals displays an intermediate or mixed pattern. Some commercially available assays further subdivide LDL-C into 7 distinct designations based on particle size.9,10

LDL Lipoprotein Particle Number

LDL particle number (LDL-P) is a measure of the number of lipoprotein particles independent of the quantity of lipid within the cholesterol particle; ie, LDL-P measures the number of individual particles, not a concentration like LDL-C. It is measured using nuclear magnetic resonance technology and is unaffected by fasting status.21 Higher LDL-P measures have been associated with a higher risk of CAD. This might simply be because there are more particles susceptible to oxidation in circulation.

There are suggestions, but not definitive proof, that reducing LDL-P increases intra-LDL antioxidant capacity. The European Prospective Investigation of Cancer (EPIC)-Norfolk cohort, a study that has followed 25 663 participants (men and women aged 45-79 years) over 6 years, evaluated associations between LDL-P and risk of CAD. Compared to controls, cases of CAD had a higher number of LDL particles (LDL-P P<.0001), smaller average LDL-particle size (P=.002), and higher concentrations of small LDL particles (P<.0001).22

Once again, small, dense LDL-C were positively associated with TG and negatively associated with HDL. In another study investigating incident angina and MI with LDL-P, females, but not males, had a significantly increased odds ratio for incident MI and angina for higher LDL-P—but not for LDL size—after adjustment for LDL, age, and race. Males had increased (but not significant) point estimates showing the same relationship.23 Of note, LDL-P and non-HDL-C (ie, TC minus HDL-C, or, specifically, LDL-C plus VLDLs), added equivalently to Framingham-predicted CAD risk stratification, thus reducing our enthusiasm for this additional measurement when TC and HDL-C are routinely available.22 Based on these results, LDL-P is becoming recognized as a more-precise measure of LDL-related risk and, as it becomes more available, is likely to replace LDL-C in risk-stratification tools. Clinical availability is currently limited; however, Medicare recently began reimbursing for regular testing of LDL-P in highrisk patients, so we should see availability increase soon. There are no novel treatments based on LDL-P at this time, and data shows therapies that lower LDL-C lower LDL-P as well.

Apolipoproteins

Apolipoproteins are the protein components of plasma lipoproteins. Several different apolipoproteins have been identified and numbered; however, apoB48, apoB100, and apoA are the most commonly referenced. ApoB48 is associated with LDL particles that transport dietary cholesterol to the liver for processing. ApoB100 is found in lipoproteins originating from the liver (eg, LDL and VLDL); it transports these lipoproteins and, also, TGs to the periphery. In addition, ApoB100 is involved with the binding of LDL particles to the vascular wall, implicating itself as a key player in the development of atherogenic plaques. Importantly, there is one apoB100 molecule per hepatic-derived lipoprotein. Hence, it is possible to quantify the number of LDL/VLDL particles by noting the total apoB100 concentration.

Measurement of apoB100 has been shown in nearly all studies to outperform LDL-C and non-HDL-C as a predictor of CAD events and as an index of residual CAD risk, perhaps due to differences in measurement sensitivity between measurement methodologies. Direct measurement of apolipoproteins is superior to calculated lipid measurements. Yet, currently, apoB100 measurement is more costly than routine measurements and, because apoB100 is so closely associated with non-HDL-C (which, as mentioned previously, can be estimated by TC minus HDL-C), our enthusiasm for the clinical use of this test is limited.24 For its part, apoA is associated with HDL particles; the 2 major proteins in HDL are apoAI and apoAII. Of these, apoAI has more frequently been used to estimate HDL-C, but, in contrast to apoB100, apoAI is not unique to HDL and so the ratio of apoAI to HDL is not 1 to 1.24

Lipoprotein(a)

Lipoprotein(a)—Lp(a)—is attached to apoB. The association of Lp(a) with CAD and its ability to act as a biomarker of risk appears to be strongest in patients with hypercholesterolemia and, in particular, in young patients with premature atherosclerosis (males younger than 55 and females younger than 65). Part of the reason for this is the observation that there seem to be important threshold effects such that only very high Lp(a) levels (> 30 mg/dL) are associated with elevated vascular risk; in this regard, these increased plasma levels of Lp(a) independently predict the presence of CAD, particularly in patients with elevated LDL-C levels.28

In the Cardiovascular Health Study, a relative risk of approximately 3-fold for death from vascular events and stroke was seen in the highest quintile compared to the lowest quintile of Lp(a) but for males only, whereas no such relation existed for women.29 Lp(a) is commonly considered a marker for familial hypercholesterolemia. Lp(a) may best be used in assessing the risk of younger males with strong family histories of CVD but should not be used more generally.

Risk Factors for Cardiovascular Disease

(Exclusive of LDL Cholesterol)34

Cigarette smoking
Hypertension (BP > 140/90 mmHg or on antihypertensive medication)
Low HDL cholesterol (< 40 mg/dL)
Family history of premature CHD (CHD in first-degree male relative <
55 years; CHD in first-degree female relative < 65 years)
Age (men > 44 years; women > 54 years

In addition,

Clinical coronary heart disease,
symptomatic carotid artery disease,
peripheral arterial disease, or
abdominal aortic aneurysm

Conclusion

In the United States, treatment guidelines for high CVD risk factors are set by the National Cholesterol Education Program (NCEP) Expert Panel, which developed the third report of the Adult Treatment Panel (ATPIII).34 Treatment goals are determined according to risk stratification by LDL-C and by known additional risk factors such as smoking, low HDL, hypertension, family history, and age. Yet, clinically, decision-making is always more complex than this. Additional risk stratification can be accomplished by measuring the biomarkers discussed above, and this may potentially provide additive benefit beyond NCEP guidelines. However, we always encourage clinicians to treat known risks to goal levels before adding additional goals for treatment. In a future article we will provide further detail on treatment options for novel biomarkers.

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profile in Type 2 diabetes mellitus subjects with good glycaemic control. Diabetes Res

Clin Pract. 2001;51(2):107-114.

14. Lamarche B, Tchernof A, Mauriège P, et al. Fasting insulin and apolipoprotein B levels

and low-density lipoprotein particle size as risk factors for ischemic heart disease.

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15. St-Pierre AC, Ruel IL, Cantin B, et al. Comparison of various electrophoretic characteristics

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measurements in the fasting and nonfasting states in patients with type 2 diabetes.

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Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Bio Instrumentation in Experimental Life Sciences Research, Cardiac & Vascular Repair Tools Subsegment, Ecosystems & Industrial Concentration in the Medical Device Sector, FDA Regulatory Affairs, Frontiers in Cardiology and Cardiovascular Disorders, Health Economics and Outcomes Research, Health Law & Patient Safety, Medical Devices R&D and Inventions, Medical Devices R&D Investment, Pharmacotherapy of Cardiovascular Disease, Regulated Clinical Trials: Design, Methods, Components and IRB related issues, Technology Transfer: Biotech and Pharmaceutical, Valves & Tools, tagged Aortic valve, Aviva Lev-Ari, Columbia University Medical Center, Edward Lifescience, Percutaneous aortic valve replacement, TAVR, Transcatheter Aortic Valve Implantation on September 3, 2012| 4 Comments »

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis

Reporter: Aviva Lev-Ari, PhD, RN

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis

Raj R. Makkar, M.D., Gregory P. Fontana, M.D., Hasan Jilaihawi, M.D., Samir Kapadia, M.D., Augusto D. Pichard, M.D., Pamela S. Douglas, M.D., Vinod H. Thourani, M.D., Vasilis C. Babaliaros, M.D., John G. Webb, M.D., Howard C. Herrmann, M.D., Joseph E. Bavaria, M.D., Susheel Kodali, M.D., David L. Brown, M.D., Bruce Bowers, M.D., Todd M. Dewey, M.D., Lars G. Svensson, M.D., Ph.D., Murat Tuzcu, M.D., Jeffrey W. Moses, M.D., Matthew R. Williams, M.D., Robert J. Siegel, M.D., Jodi J. Akin, M.S., William N. Anderson, Ph.D., Stuart Pocock, Ph.D., Craig R. Smith, M.D., and Martin B. Leon, M.D. for the PARTNER Trial Investigators

N Engl J Med 2012; 366:1696-1704 May 3, 2012

Background

Transcatheter aortic-valve replacement (TAVR) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The outcomes beyond 1 year in such patients are not known.

Methods

We randomly assigned patients to transfemoral TAVR or to standard therapy (which often included balloon aortic valvuloplasty). Data on 2-year outcomes were analyzed.

Results

A total of 358 patients underwent randomization at 21 centers. The rates of death at 2 years were 43.3% in the TAVR group and 68.0% in the standard-therapy group (P<0.001), and the corresponding rates of cardiac death were 31.0% and 62.4% (P<0.001). The survival advantage associated with TAVR that was seen at 1 year remained significant among patients who survived beyond the first year (hazard ratio, 0.58; 95% confidence interval [CI], 0.36 to 0.92; P=0.02 with the use of the log-rank test). The rate of stroke was higher after TAVR than with standard therapy (13.8% vs. 5.5%, P=0.01), owing, in the first 30 days, to the occurrence of more ischemic events in the TAVR group (6.7% vs. 1.7%, P=0.02) and, beyond 30 days, to the occurrence of more hemorrhagic strokes in the TAVR group (2.2% vs. 0.6%, P=0.16). At 2 years, the rate of rehospitalization was 35.0% in the TAVR group and 72.5% in the standard-therapy group (P<0.001). TAVR, as compared with standard therapy, was also associated with improved functional status (P<0.001). The data suggest that the mortality benefit after TAVR may be limited to patients who do not have extensive coexisting conditions. Echocardiographic analysis showed a sustained increase in aortic-valve area and a decrease in aortic-valve gradient, with no worsening of paravalvular aortic regurgitation.

Conclusions

Among appropriately selected patients with severe aortic stenosis who were not suitable candidates for surgery, TAVR reduced the rates of death and hospitalization, with a decrease in symptoms and an improvement in valve hemodynamics that were sustained at 2 years of follow-up. The presence of extensive coexisting conditions may attenuate the survival benefit of TAVR. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.)

Supported by Edwards Lifesciences.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMoa1202277) was published on March 26, 2012, and updated on August 30, 2012, at NEJM.org.

Source Information

From Cedars–Sinai Heart Institute, Los Angeles (R.R.M., H.J., R.J.S.); Lenox Hill Heart and Vascular Institute (G.P.F.) and Columbia University Medical Center and New York Presbyterian Hospital (S. Kodali, J.W.M., M.R.W., C.R.S., M.B.L.) — both in New York; Cleveland Clinic Foundation, Cleveland (S. Kapadia, L.G.S., M.T.); Washington Hospital Center, Washington, DC (A.D.P.); Duke University School of Medicine, Durham, NC (P.S.D.); Emory University School of Medicine, Atlanta (V.H.T., V.C.B.), University of British Columbia and St. Paul’s Hospital, Vancouver, Canada (J.G.W.); Hospital of the University of Pennsylvania, Philadelphia (H.C.H., J.E.B.); Baylor Healthcare System (D.L.B., B.B.) and Medical City Dallas (T.M.D.) — both in Dallas; Edwards Lifesciences, Irvine, CA (J.J.A., W.N.A.); and London School of Hygiene and Tropical Medicine, London (S.P.).

Address reprint requests to Dr. Leon at Columbia University Medical Center, Center for Interventional Vascular Therapy, 161 Fort Washington Ave., 6th Fl., New York, NY 10032, or at mleon@crf.org.

The investigators, institutions, and research organizations participating in the Placement of Aortic Transcatheter Valves (PARTNERS) trial are listed in the Supplementary Appendix, available at NEJM.org.

http://www.nejm.org/doi/full/10.1056/nejmoa1202277

Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Bio Instrumentation in Experimental Life Sciences Research, Cardiac & Vascular Repair Tools Subsegment, Ecosystems & Industrial Concentration in the Medical Device Sector, Exec Compensation in the Cardiac & Vascular Repair Tools Subsegment, Frontiers in Cardiology and Cardiovascular Disorders, Massachusetts Niche Suppliers and National Leaders, Medical Devices R&D and Inventions, Mitral Valve: Repair and Replacement, Stents & Tools, Valves & Tools, tagged Aortic valve, Coronary stent, Edwards Lifesciences, Edwards Lifesciences Corporation, Industry Concentration Ratio in Medical Devices Markets, Market Penetration Cost, Market Penetration in Medical Devices Market, Niche supplier, Peripheral, Stent, Vascular surgery on June 22, 2012| 12 Comments »

Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites

Curator: Aviva Lev-Ari, PhD, RN

The ecosystem of Cardiac and Vascular Surgery for Repair or Replacement by Implantation of a new blood vessel or medical device covers the following procedure-related devices and tools now in use:

Arterial catheterization kit
Embolectomy catheters
Occlusion catheter
Coronary stents
Neurovascular stents
Carotid stents
External and internal carotid shunts
Peripheral stents
Biliary stents
Micro vascular clips
Stainless steel tunneler vascular graft
Cardiopulmonary bypass vascular catheter
Coronary stent graft system
Catheter tip occluder
Synthetic/biological composite vascular graft
Valvulotome tools
Aortic Valve
Mitral Valve
Angioplasty Guided Wires

No Aorta valve suppliers in MA. The National Leader supplier Edwards Lifesciences and its SAPIEN product for Transcatheter Aortic-Valve Implantation (TAVI) and Replacement (TAVR) is covered in Executive Compensation and Comparator Group Definition in the Cardiac and Vascular Medical Devices Sector: A Bright Future for Edwards Lifesciences Corporation in the Transcatheter Heart Valve Replacement Market 6/20/2012

Medical Devices Market in Massachusetts: Product Concentration Ratios (1 to 10) by Product and Partnership Target Advantage – Niche Suppliers vs. National Leader in the Cardiology & Vascular Surgery Tools and Devices in use in Cardiac Operating Rooms and in Angioplasty Suites

Industry Concentration Ratios per Product Line in the Cardiac and Vascular Medical Devices Segments
A	B	C	D	E	F	G	H	I	J
		US comparison				MA comparison
Cardiology & Vascular Surgery Tools and Devices in use	Global Suppliers	US Suppliers	Market share	Global ratio	Index	MA Suppliers	Market share	Global ratio	Index
Arterial catheterization kit	4	6	0.09	0.40	5.6	2	0.14	0.67	3.6
Embolectomy catheters	11	28	0.03	0.28	1.9	3	0.07	0.79	2.4
Occlusion catheter	1	7	0.11	0.13	2.8	3	0.20	0.25	2.4
Coronary stents	11	34	0.02	0.24	1.7	2	0.07	0.85	2.6
Neurovascular stents	2	6	0.11	0.25	4.5	1	0.25	0.67	5.5
Carotid stents	1	12	0.07	0.08	1.7	1	0.33	0.50	5.5
External and internal carotid shunts	2	5	0.13	0.29	5.5	2	0.20	0.50	3.7
Peripheral stents	0	7	0.13	0.00	1.0	1	0.50	0.00	1.0
Biliary stents	7	13	0.05	0.35	3.1	1	0.11	0.88	3.6
Micro vascular clips	3	6	0.10	0.33	5.2	2	0.17	0.60	3.7
Stainless steel tunneler vascular graft	3	3	0.14	0.50	10.0	1	0.20	0.75	5.1
Cardiopulmonary bypass vascular catheter	14	39	0.02	0.26	1.6	5	0.05	0.74	2.0
Coronary stent graft system	0	6	0.14	0.00	1.0	1	0.50	0.00	1.0
Catheter tip occluder	1	6	0.13	0.14	3.3	2	0.25	0.33	3.3
Synthetic/biological composite vascular graft	3	5	0.11	0.38	6.3	2	0.17	0.60	3.7
Valvulotome tools	3	6	0.10	0.33	5.2	1	0.20	0.75	5.1
Aortic Valve	2	9	0.08	0.18	2.9	0	0.33	1.00	10.0
Mitral Valve	4	7	0.08	0.36	4.8	0	0.20	1.00	6.4
Angioplasty Guided Wires	8	11	0.05	0.42	3.7	2	0.09	0.80	3.0
					126				27
Source for A, B, C, G – http://www.medicregister.com
Source for D,E,F,H,I,J – Computed ratios per formulas below byAviva Lev-Ari, PhD, RN
D = 1/(1+B+C) = projected market share assuming non-differential production capacity

E = B/(B+C) = fraction of global among all suppliers

F = DE$F$24+1 = product of “D” and “E”, scaled to be in the range from 1 to 10

“H” is the same as “D” but with MA suppliers replacing “US suppliers”
“I” is the same as “E” but with MA suppliers replacing “US suppliers”
“J” is the same as “F” but with MA suppliers replacing “US suppliers”

Product Advantage for Partnership with Niche Suppliers in MA

Product Concentration Ratio (PRC) for Tools and Devices in use in Cardiology & Vascular Surgery	Targeting a Niche Supplier based in Massachusetts	Aiming at the Industry Leader
Arterial catheterization kitPRC = 3.6	Lemaitre Vascular, Inc. www.lemaitre.comBurlington Smiths Medical ASD, Inc Weston
External and internal carotid shuntsPRC = 3.7	Bard Electrophysiology www.bardep.comLowell Lemaitre Vascular, Inc. www.lemaitre.com Burlington
Micro vascular clipsPRC = 3.7	Lemaitre Vascular, Inc. www.lemaitre.comBurlington Life Instrument Corporation www.lifeinstruments.com Braintree
Stainless steel tunneler vascular graftPRC = 5.1	Lemaitre Vascular, Inc. www.lemaitre.comBurlington
Cardiopulmonary bypass vascular catheterPRC = 2	Abiomed, Inc. www.abiomed.comDanvers Vortex Medical Inc www.angiovac.com Norwell Lemaitre Vascular, Inc. www.lemaitre.com Burlington Clinical Instruments Intl., Inc. Southbridge Smiths Medical ASD, Inc Weston
Coronary stent graft systemPRC = 2.6	Lemaitre Vascular, Inc. www.lemaitre.comBurlington
Catheter tip occluderPRC = 2.4	Lemaitre Vascular, Inc. www.lemaitre.comBurlington Clinical Instruments Intl., Inc. Southbridge
Valvulotome toolsPRC = 5.1	Lemaitre Vascular, Inc. www.lemaitre.comBurlington

Product Advantage for Partnership with National Leader in MA

Cardiology & Vascular Surgery Tools and Devices in use	Niche Supplier based in Massachusetts	Industry Leader
Neurovascular stentsPRC = 5.5		Boston Scientific Corporation www.bostonscientific.comNatick
Carotid stents PRC = 5.5		Boston Scientific Corporation www.bostonscientific.comNatick
Peripheral stentsPRC = 1		Boston Scientific Corporation www.bostonscientific.comNatick
Biliary stentsPRC = 3.6		Boston Scientific Corporation www.bostonscientific.comNatick

Product Advantage for Partnership with Niche Suppliers and National Leader in MA

Cardiology & Vascular Surgery Tools and Devices in use	Niche Supplier based in Massachusetts	Industry Leader
Embolectomy cathetersPRC = 2.4	Lemaitre Vascular, Inc. www.lemaitre.comBurlington Clinical Instruments Intl., Inc. Southbridge	Boston Scientific Corporation www.bostonscientific.comNatick
Occlusion catheterPRC = 2.4	Lemaitre Vascular, Inc. www.lemaitre.comBurlington Telemed Systems Inc. www.telemedsystems.com Hudson	Boston Scientific Corporation www.bostonscientific.comNatick
Coronary stentsPRC = 2.6	Lemaitre Vascular, Inc. www.lemaitre.comBurlington	Boston Scientific Corporation www.bostonscientific.comNatick
Synthetic/biological composite vascular graftPRC = 3.7	Lemaitre Vascular, Inc. www.lemaitre.comBurlington	Boston Scientific Corporation www.bostonscientific.comNatick
Angioplasty Guided WiresPRC = 3.0	Arrow International, Walrus DivisionWoburn	Boston Scientific Corporation www.bostonscientific.comNatick

Source:

http://www.medicregister.com/Cardiology_Vascular_Surgery/Categories/cid2.htm

Penetration Strategy for a Global Supplier Targeting the US Market in Massachusetts

Customized predictions of penetration cost and estimation of potential revenues based on the industry segment concentration ratios in the Table above per Partnership Option are part of an Actionable Strategic Market Entry Plan in Massachusetts.

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Executive Compensation and Comparator Group Definition in the Cardiac and Vascular Medical Devices Sector: A Bright Future for Edwards Lifesciences Corporation in the Transcatheter Heart Valve Replacement Market

Posted in Aortic Valve: TAVR, TAVI vs Open Heart Surgery, Cardiac & Vascular Repair Tools Subsegment, Ecosystems & Industrial Concentration in the Medical Device Sector, Exec Compensation in the Cardiac & Vascular Repair Tools Subsegment, Frontiers in Cardiology and Cardiovascular Disorders, Health Economics and Outcomes Research, Medical Devices R&D and Inventions, Medical Devices R&D Investment, Uncategorized, Valves & Tools, tagged Aortic valve, Aortic valve stenosis, Cardiac surgery, Edwards Lifesciences Corporation, Edwards SAPIEN, Food and Drug Administration, Heart valve, PARTNER II Clinical Trial, Total stockholder return (TSR), Transcatheter Aortic Valve Replacement (TAVR) on June 19, 2012| 16 Comments »

Curator: Aviva Lev-Ari, PhD, RN

Edwards Lifesciences Corporation, Irvine, California delivers acute hemodynamic monitoring & heart valves. Their new perimount magna heart valve (bioprosthesis), with its supra-annular design, offers optimal hemodynamics and flow characteristics for treatment of aortic heart valve diseases. Their embolectomy catheters are indicated for the removal of fresh, soft emboli and thrombi from vessels in the arterial system.

Edwards Lifesciences Reports Strong 2012 Fourth Quarter Results

February 5, 2013

IRVINE, CA, February 04, 2013 — Edwards Lifesciences Corporation (NYSE: EW), the global leader in the science of heart valves and hemodynamic monitoring, today reported net income for the quarter ended December 31, 2012, of $91.1 million, or $0.77 per diluted share, compared to net income of $63.1 million, or $0.53 per diluted share, for the same period in 2011.

During the quarter, the company recorded a global realignment pretax charge of $9.0 million, primarily related to severance costs. Additionally, in its non-GAAP results for the quarter, the company included an $8.4 million tax benefit, which represents the portion of the recently renewed Federal research and development (R&D) tax credit that is retroactive to the beginning of 2012. In the quarter ending March 31, 2013, the company will record the 2012 tax credit as required, but will exclude it from non-GAAP results. The impact of these special items was $0.13 per diluted share.

Adjusting for special items from both periods detailed in the reconciliation table below, fourth quarter diluted earnings per share were $0.90, compared to $0.62 in the prior year quarter, an increase of 45.2 percent.

Fourth quarter net sales increased 18.7 percent to $510.5 million compared to the same period last year. Sales growth excluding the impact of foreign exchange was 21.2 percent.

“Our fourth quarter capped a year of significant progress as we introduced our innovative SAPIEN technology to the U.S.,” said Michael A. Mussallem, chairman and CEO. “We are very proud that more than 5,000 patients in the U.S. have been treated with our transcatheter valves since launch, and we are aggressively investing to expand the availability of this important therapy. In spite of a difficult economic environment, underlying(1) sales were up 16 percent in 2012 driven by a strong finish in each of our product lines.”

Sales Results
For the fourth quarter, the company reported Surgical Heart Valve Therapy product group sales of $197.7 million, which included $29.1 million of cardiac surgery systems sales. Sales grew 3.8 percent over the fourth quarter last year, or 5.5 percent excluding the impact of foreign exchange. Growth outside the U.S. was 4.0 percent, or 7.2 percent excluding the impact of foreign exchange, while sales in the U.S. grew 3.5 percent.

Sales of transcatheter heart valves (THV) were $161.0 million for the quarter, a 72.8 percent growth over the fourth quarter last year, or 77.2 percent excluding the impact of foreign exchange. These results were driven by the ongoing U.S. launch of the SAPIEN valve, with total U.S. THV sales of $80.7 million. Outside the U.S., sales grew by 5.5 percent, or 10.0 percent excluding the impact of foreign exchange.

“We continue to expect underlying transcatheter heart valve sales to grow 30 to 45 percent in 2013. This would result in global sales of $710 million to $790 million, which includes $390 million to $440 million of sales in the U.S.,” Mussallem said.

Critical Care product group sales were $151.8 million for the quarter, including vascular sales of $13.8 million. Critical care sales were $138.0 million, representing growth of 3.5 percent, or 6.0 percent excluding the impact of foreign exchange. Growth was driven primarily by advanced monitoring products in Japan and the U.S.

Domestic and international sales for the fourth quarter were $224.9 million and $285.6 million, respectively.

Additional Operating Results
For the quarter, Edwards’ gross profit margin was 75.4 percent, compared to 72.2 percent in the same period last year. This improvement was driven primarily by a more profitable product mix and the impact from foreign exchange.

Selling, general and administrative expenses were $177.9 million for the quarter, or 34.8 percent of sales, compared to $163.4 million, or 38.0 percent of sales, in the same period last year. The increase in expenses was driven primarily by U.S. transcatheter launch-related investments.

Research and development for the quarter grew 23.4 percent to $74.9 million, or 14.7 percent of sales. This increase was the result of additional investments in clinical studies and new product development efforts in all of the company’s product lines.

Free cash flow for the quarter was $70.6 million, defined as cash flow from operating activities of $126.4 million, less capital spending of $55.8 million.

Cash and cash equivalents and short-term investments were $521.4 million at the end of the quarter. Total debt at December 31, 2012, was $189.3 million.

During the quarter, the company repurchased approximately 2.1 million shares of common stock for $186.9 million. At December 31, 2012, approximately $248 million was available for share repurchase under the company’s existing share repurchase authorization.

Twelve-Month Results
For the twelve months ended December 31, 2012, the company recorded net income of $293.2 million, or $2.48 per diluted share, compared to $236.7 million, or $1.98 per diluted share, for the same period in 2011. On a non-GAAP basis, earnings per diluted share were $2.69, compared to $2.02, a 33.2 percent increase.

Net sales for the twelve months of 2012 increased 13.2 percent to $1.90 billion. Underlying sales growth was 16.2 percent.

Domestic and international sales for the twelve months were $812.1million and $1,087.5 million, respectively.

Free cash flow for the year was $253.1 million, defined as cash flow from operating activities of $373.8 million, less capital spending of $120.7 million.

During 2012, the company repurchased approximately 4.0 million shares of common stock for $353.2 million.

Outlook
“We expect another exciting year for Edwards Lifesciences with continued strong sales growth, greater operating leverage, and progress on a number of important clinical milestones,” Mussallem said. “To strengthen our leadership position we plan to continue investing substantially in the development of transcatheter valves and other structural heart disease therapies, as well as in critical care technologies. We believe our focused innovation strategy, together with our global presence and strong financial footing, uniquely position us to drive strong, sustainable growth, while we help treat additional patients.

“We continue to expect full year sales of $2.1 billion to $2.2 billion and earnings per diluted share, excluding special items, of $3.21 to $3.31,” said Mussallem. “For the first quarter 2013, we project total sales of $505 million to $530 million and diluted earnings per share, excluding the $0.07 benefit from the 2012 R&D tax credit and any other special items, between $0.74 and $0.78.”

SOURCE:

http://www.fiercemedicaldevices.com/press-releases/edwards-lifesciences-reports-strong-fourth-quarter-results?utm_medium=nl&utm_source=internal

History of Edwards Lifesciences

Edwards Lifesciences’ roots date to 1958, when Miles “Lowell” Edwards set out to build the first artificial heart.  Edwards was a 60-year-old, recently retired engineer holding 63 patents in an array of industries, with an entrepreneurial spirit and dreams of helping patients with heart disease. His fascination with healing the heart was sparked in his teens, when he suffered through two bouts of rheumatic fever, which can scar heart valves and eventually cause the organ to fail.

With a background in hydraulics and fuel pump operations, Edwards believed the human heart could be mechanized. However, when he presented the concept to Dr. Albert Starr, a young surgeon at the University of Oregon Medical School, the idea was met with hesitation. Instead, Starr encouraged Edwards to focus first on developing an artificial heart valve, for which there was an immediate need.   After only two years, the first Starr-Edwards mitral valve- which is not longer available for sale – was designed, developed, tested, and successfully placed in a patient. Newspapers around the world reported on what they termed a “miraculous” heart surgery.   This innovation spawned a company, Edwards Laboratories, which set up shop in Santa Ana, Calif. — not far from where Edwards Lifesciences’ global headquarters is located today.

Edwards Lifesciences’ heart valve expertise has led to the development of one of the most exciting opportunities in the cardiovascular field – transcatheter heart valve replacement. The specially-designed valve and delivery system* is being evaluated in clinical studies in which high-risk patients receive a valve replacement without traditional open-heart surgery and while their heart continues to beat. Clinicians replace a patient’s aortic valve via a catheter inserted into a small incision in either the leg or between the ribs. Edwards Lifesciences’ leadership in transcatheter heart valve replacement includes a commitment to rigorous scientific study of the procedure and to extensive clinician training and education.  Consistent with this effort to explore less invasive surgery, the company is committed to providing tools for minimally invasive cardiac surgery that allow cardiac surgeons to perform heart valve operations through small openings, or “ports,” in the spaces between the ribs.

http://cardiovascular.eng.uci.edu/edwardslifesciences/history

In patients with severe aortic stenosis who were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.)

The PARTNER II Trial: Placement of AoRTic TraNscathetER Valves

This study is currently recruiting participants.

Verified May 2012 by Edwards Lifesciences

First Received on March 7, 2011. Last Updated on May 23, 2012 History of Changes

Sponsor:	Edwards Lifesciences
Information provided by (Responsible Party):	Edwards Lifesciences
ClinicalTrials.gov Identifier:	NCT01314313

Purpose

The purpose of this trial is to determine the safety and effectiveness of the Edwards SAPIEN XT transcatheter heart valve and delivery systems: NovaFlex (transfemoral access) and Ascendra2 (transapical access) in patients with symptomatic, calcific, severe aortic stenosis.

Condition	Intervention	Phase
Symptomatic Severe Aortic Stenosis	Device: TAVR Implantation of the Transcatheter Aortic Valve ProsthesisDevice: AVR with a surgical heart valveDevice: TAVR Implantation of the Transcatheter Aortic Valve ProsthesisDevice: TAVR Implantation of the Transcatheter Aortic Valve Prosthesis	Phase 3

Study Type:	Interventional
Study Design:	Allocation: RandomizedEndpoint Classification: Safety/Efficacy StudyIntervention Model: Parallel AssignmentMasking: Open LabelPrimary Purpose: Treatment
Official Title:	The PARTNER II Trial “Placement of AoRTic TraNscathetER” Valves Trial” (US) [Edwards Study 2010-12]

http://www.clinicaltrials.gov/ct/show/NCT01314313?order=4

Unparalleled Commitment to Research

The research vision for The Edwards Lifesciences Center for Advanced Cardiovascular Technology is a dynamic process and will be developed and implemented by the Center and faculty.

The broad vision will encompass basic research and development of new technologies focused on the treatment of cardiovascular disease.

The breadth of this vision will allow the flexibility to recruit the most outstanding faculty in the cardiovascular field, as well as allow the Center’s research activity to move quickly into new areas while remaining focused in the cardiovascular system. Potential areas of expertise and focus will include, but are not limited to:

Valve replacement technology
Regenerative and degenerative cardiovascular medicine (including tissue engineering and stem cell biology)
Non-invasive (wireless) cardiovascular monitoring, intervention, and imaging
Novel stent or catheter-based therapies including new biological coatings

The engineering expertise that will be applied to these areas include Micro-Electro-Mechanical Systems (MEMS), nanotechnology, biophotonics, biomaterials, systems biology, and computation/modeling.

Core Facilities

The Center has three fully functional core research facilities, and a fourth facility in the final planning stages. The facilities will provide unique and/or synergistic instrumentation and expertise for the campus and community. Access to the core facilities is limited to faculty members who are members of the Center and their trainees. The core facilities are briefly described below, and more information about the instrumentation, access, training, and reservations can be found on each facility’s page:

1. Surgical and Imaging Facility (SIF). The SIF is currently in a planning stage. This facility could potentially provide a major resource to the campus, not only for cardiovascular research, but other organ systems that need small and large animal models, as well as training opportunities for UC Irvine and community-based cardiologists, scientists, or sales representatives from local companies. The planned facility will include the following functionalities:

Complete catheterization including hemodynamic monitoring with bi-plane fluoroscopic imaging

Ultrasound

MicroCT

MicroPET (positron emission tomography)

MicroSPECT (single positron emission computed tomography)

OCT (optical computed tomography)

In addition to the catheterization lab, a fully functional operating room for both acute and chronic procedures are planned.

2. Cell and Tissue Facility (CTF). The Cell and Tissue Facility, located in Engineering Hall rooms 2110 and 2128, is a complete cell-culturing facility. The center offers six biosafety cabinets, two water baths, six CO2 incubators – including one for oxygen tension control – two benchtop incubators – including one for oxygen tension control – centrifuges with refrigeration capabilities, three cell culture microscopes, refrigeration, -80C and -20C freezers, liquid nitrogen storage, and a purified water source.

3. Mechanical Testing Facility (MTF). This core facility provides two basic instruments for investigating mechanical properties. The Synergie 100 system performs tension or compression testing, while the rheometer provides the capability to study dynamic and shear properties. The instruments are housed in Engineering Hall room 2115.

4. Microscopy Core Facility (MCF). Microscopy Core Facility has multiple imaging capabilities, including confocal, fluorescence, differential interference contrast, phase contrast, darkfield, and brightfield microscopy. This core facility is equipped with a Nikon Eclipse TE300 Inverted Scope with Nikon PCM2000 Confocal Attachment, an Inverted Eclipse TE300, and an Upright Eclipse E800 w/ VFM epi-fluorescence attachment. Each microscopy is equipped with a 12-bit CCD camera; specifications can be found on the facility’s website.

http://cardiovascular.eng.uci.edu/book/export/html/12

Executive Compensation in the Cardiology and Cardiac Surgery Medical Devices Market: Comparison of Edwards Lifesciences Corporation with other Suppliers – Analysis of the SAPIEN Contribution

Edwards Lifesciences Corporation

NOTICE OF 2012 ANNUAL MEETING OF STOCKHOLDERS

To be held on Thursday, May 10, 2012

http://ht.edwards.com/sci/edwards/sitecollectionimages/edwards/investorrelations/2012edwardsproxy.pdf

Definition of a Comparator Group for Determination of Executive Compensation. Edwards Lifesciences 2011 Comparator Group include:

Allergan, Inc.

Masimo Corp.

Becton Dickinson & Co.

Medtronic, Inc.

Boston Scientific Corp.

PerkinElmer, Inc.

C. R. Bard, Inc.

ResMed, Inc.

CareFusion, Inc.

St. Jude Medical, Inc.

Covidien plc

Stryker Corp.

Gen-Probe, Inc.

Thoratec Corp.

Hospira, Inc.

Varian Medical Systems, Inc.

Illumina, Inc.

Zimmer Holdings, Inc.

Integra Lifesciences Holding Corp.

http://ht.edwards.com/sci/edwards/sitecollectionimages/edwards/investorrelations/2012edwardsproxy.pdf

p.28

In the Chairman of the board address: 2011 Performance was Strong. The year 2011 was one of significant investment and major milestones. Successful PARTNER trial results culminated in U.S. regulatory approval to begin commercially offering the SAPIEN transcatheter heart valve to many inoperable patients. We developed a rigorous training program to promote the teamwork of cardiac surgeons and interventional cardiologists, and to emphasize excellent clinicalresults. To support expected growth, we expanded our heart valve manufacturing capacity, and made additional enhancements to our infrastructure, including our information and quality systems.As a result of the combined efforts of our management team and their employees, in 2011, theCompany delivered another year of strong financial performance. The company-wide financial measures usedto determine 2011 incentive compensation consisted of goals for revenue growth, net income, and free cashflow.

The following table shows the 2011 results for these three metrics compared against the 2011 targets and the comparable performance measures for 2010 and 2009:

2011 2011 2010 2009

Actual Target Actual Actual

Revenue Growth* . . . . . . . . . . . . . . . . . . . . . 11.0%** 11.4%** 12.7% 11.4%

Net Income* . . . . . . . . . . . . . . . . . . . . . . . . $259.6** $244.0** $218.9 $181.5

Free Cash Flow* . . . . . . . . . . . . . . . . . . . . . $215.0** $215.0** $196.2 $178.1

http://ht.edwards.com/sci/edwards/sitecollectionimages/edwards/investorrelations/2012edwardsproxy.pdf

p.25

	Comparison of Cumulative Five Year Total Stock Return
	2007	2008	2009	2010	2011
Edwards Life Sciences	98	117	185	344	301
S&P	104	64	79	89	89
Morgan Stanley Health Care Products	103	82	102	109	115
http://ht.edwards.com/sci/edwards/sitecollectionimages/edwards/investorrelations/2012edwardsproxy.pdf p.26

Pay for Performance Philosophy.The Compensation Committee strongly believes that executive compensation should be tied to performance and strives to create a pay for performance culture. Our compensation objectives are to offer programs that emphasize performance-based compensation and align the financial interests of our executives with those of the Company’s stockholders. Accordingly, approximately 80% of the total direct compensation of our Chairman of the Board and Chief Executive Officer (the ‘‘Chairman and CEO’’) and our Named Executive Officers is at risk based upon the performance of the Company. p.26

Company	CEO TDC (Average) (in thousands)
Company	Most Recent FY	Last 3 FYs	Last 5 FYs
2011 Comparatoe Group
90th Percentile	$10,627	$11,110	$10,398
75th Percentile	$9,590	$10,012	$9,143
Median	$7,839	$7,748	$7,836
25th Percentile	$5,011	$5,008	$5,228
Edwadrs Lifesciences	$5,829	$5,789	$5,567
Percentile	36.60%	33.90%	26.60%
http://ht.edwards.com/sci/edwards/sitecollectionimages/edwards/investorrelations/2012edwardsproxy.pdf p.29

When compared to the competitive data based on the 2011 Comparator Group, the average base salary compensation paid to the Named Executive Officers for the 2011 fiscal year was approximately 2.5% below the median, the total cash compensation was at the median, and total direct compensation was approximately at the median. The following chart illustrates the total direct compensation of our Chairman and CEO.

The total stockholder return (TSR) for the Company’s common stock for the previous one, three, and five years, compared to the data of our 2011 Comparator Group:

2011 Edwards Most Recent Return: -11.8%, 42 percentile

Last 3 FYs 55.6%, maximum percentile

Last 5 FYs 37.3%, maximum percentile

2011 Comparator Group: 90^th percentile subgroup, Most Recent TSR 7.6%

Last 3 FYs 18.9%

Last 5 FYs 8.5%

Executive compensation at Edwards in 2012 will increase significantly as a direct results from the Edwards’ stock soars after FDA panel nod on expanded Sapien valve use

On June 14, 2012:

Stock Price and Trading Volume 7/2011 to 6/14/2012

http://www.dailyfinance.com/quote/nyse/edwards-lifesciences-corp/ew/charts

Stock Price and Trading Volume 5/21/2012 to 6/14/2012

http://www.dailyfinance.com/quote/nyse/edwards-lifesciences-corp/ew/charts

Edwards Lifesciences Corp. (EW) won the backing of U.S. advisers for an expanded use of the company’s Sapien heart valve as an alternative to open-heart surgery. Edwards’ transcatheter aortic heart valve may soon have two indications: for aortic stenosis patients who are both inoperable and at high risk for surgery.

Smith, PARTNER trial’s principal investigator of Cohort A during the sponsor presentation, urged that the higher frequency of neurological events that occurred within the TAVR group should not be “trivialized” in either treatment group. Smith called aortic stenosis “one of the conditions we understand best in cardiovascular disease.” He called transcatheter aortic valve replacement (TAVR) a “miracle therapy,” and said that outcomes for the procedure will only continue to improve. And while most of the day’s conversation gave kudos to the PARTNER trial and its findings, concerns did focus on gender differences and neurological events.

Mark Hollmer explains that Edwards Lifesciences ($EW) scored a major win on Wednesday, successfully making its case before an FDA panel of experts that its Sapien transcatheter heart valve should be used in a broader class of patients. The agency’s Circulatory Systems Advisory Committee voted 11-0 (one panelist abstained) that the benefits outweighed any risks in using the valve for patients with severe aortic stenosis who are high-risk but could otherwise undergo surgery.

Investors reacted favorably, driving Edwards’ stock up more than 8% to $98.55 by midday on June 14. Bloomberg, MedPage Today, The Associated Press, CardiovascularBusiness and many others covered the day-long panel meeting and final vote. While the FDA doesn’t have to follow the panel’s recommendation, it usually does. Panel members also voted 12-0 that Sapien is effective and 10-2 that the valve is safe.

When the FDA comes out with its final decision is anyone’s guess, but Bloomberg predicts final action could come in October, based on the timeline for Sapien’s initial approval in 2011 (panel meeting in July; regulatory approval in November). Sapien initially gained FDA approval for patients with limited classes of stenosis who can’t have surgery.

To make its case during the 8-hour-plus hearing, Edwards Life Sciences relied on the “Cohort B” part of its pivotal PARTNER trial, which compared transcatheter aortic valve implantation (TAVI) with surgery. (“Cohort A” was used for the initial approval in November.) PARTNER recruited 699 high-risk older patients with severe aortic stenosis and randomly assigned them to TAVI (n=348) or surgery. About two-thirds of the TAVI patients underwent transfemoral procedures, where the device was threaded through the femoral artery, while 103 had transapical access procedures, where the device was inserted directly into the tip of the left ventricle of the heart.

Death rates were essentially the same at 1 year for the Sapien group and the control group. When divided up by type of valve implantation compared with matched surgery controls, the death rate for Sapien implanted via a transfemoral approach was 24.2% versus 26.8% for surgery; and for the transapical approach the 1-year mortality rate was 22.2% for the Sapien group and 26.4% for the open-heart surgery group. Although the death rate was very similar, TAVI patients had double the rate of stoke during the 30-day period following the procedure. With the transapical approach, there appeared to be an even greater increased risk for early stroke, which the panel chalked up to the fact that patients who received TAVI via transapical approach were sicker patients, so their outcomes were poorer than those who were implanted via a transfemoral approach.

The trial involved 699 older patients of high risk with severe aortic stenosis who were randomly assigned to the TAVI procedure or surgery. Among the findings: the death rate was similar for both, but patients who had transcatheter aortic valve implantation faced double the rate of stroke over the initial 30-day period after the surgery. That finding concerned both FDA scientists and panel members, though Edwards countered that stroke rates evened out after another year, Bloomberg notes. Regulators in advance of the hearing were also bothered by how the company chose patients and categorized them for the trial, arguing that it constituted bias to some degree, and potentially skewed the results.

Edwards wants to do a post-approval study to follow patients from the trial and also create a registry to enroll new patients. FDA staff members agree, and urged at least 5 years of follow-up for subjects from the trial.

http://www.fiercemedicaldevices.com/story/edwards-lifesciences-argue-expanded-sapien-valve-use/2012-06-12?utm_medium=nl&utm_source=internal

http://www.medpagetoday.com/Cardiology/PCI/33263

Transcatheter Heart Valve Replacement Market: A Market of $2.5 Billion in the US

The market for transcatheter valves may total $2.5 billion in the U.S., said Jason Mills, a San Francisco-based analyst with Canaccord Adams Inc. The initial FDA approval of Sapien in November boosted Edwards’s sales 67 percent in the first quarter to $122 million, Michael Mussallem, the company’s chairman and chief executive officer, said in an April 24 earnings call.

The device is meant to treat aortic stenosis. The debilitating condition is caused by a narrowing valve that restricts the ability of blood to enter the aorta, the main artery that carries blood from the heart, according to the National Institutes of Health.

“A broader indication for high-risk patients would enable multidisciplinary heart teams to choose the approach best suited to their patients’ needs,” Mussallem said in a statement after the panel’s vote. “We look forward to working closely with the FDA during the review process, and thank the panel for their thoughtful analysis.”

The FDA may decide on approval in October if reviewers follow the same timeline they did when they cleared the valve for inoperable patients. Advisers met in July to consider the device for inoperable patients and approved it in November.

http://www.cardiovascularbusiness.com/index.php?option=com_articles&view=article&id=34321:sapien-makes-more-headway-in-aortic-stenosis-world

Another point of concern, as Bloomberg points out: FDA staff noted that patients treated with Sapien faced twice the stroke risk in the initial month after the implant procedure, compared to patients who had open-heart surgery instead.

The FDA wants the company to commit to a long-term follow up, post-approval study that tracks patients for at least 5 years to address its concerns. Edwards appears to be on the same page, having proposed a post-approval study that would follow patients from its pivotal trial, as well as a new patient registry, according to the story.

http://www.fiercemedicaldevices.com/story/edwards-lifesciences-argue-expanded-sapien-valve-use/2012-06-12?utm_medium=nl&utm_source=internal

Edwards won a PMA for the Sapien device for inoperable patients with aortic stenosis, a hardening and narrowing of the aortic valve, in November 2011.* FDA reviewers said the arm of the study covering the high-risk patients may have been flawed by the inconsistencies.

“FDA notes that screening and subsequent enrollment practices were not homogenous. The large variation between the ratios of those screened to those enrolled may represent different selection criteria among sites,” according to documents released ahead of the meeting scheduled for Wednesday. “Enrollment practices related to identification of ‘inoperable’ and ‘high risk’ patients were not homogenous across sites.”

https://www.massdevice.com/news/fda-possible-selection-bias-issues-confound-edwards-sapien-study

FDA Panel

There was “no significant difference” in mortality between patients treated with surgery vs. treatment with the Sapien valve, according to the documents. But some patients who were slated for traditional open heart surgery were treated with the TAVI device, and vice-versa, making it difficult to evaluate the study’s endpoints.

“[T]he issue of [surgery] patients not receiving [surgery], [Sapien] patients receiving [surgery], and [surgery] patients undergoing concomitant operations makes evaluation of these endpoint results difficult,” according to the FDA reviewers. “Although the primary endpoint was met, issues related to potential selection bias confound the interpretation of these results.”

“We believe the Partner trial was well-designed and executed. We are proud of the efforts of the leading heart teams that supported this ground-breaking trial and what it means for patients,” an Edwards spokeswoman told MassDevice.com via email. “We are reserving further comment on this or related matters until the Advisory Committee scheduled for June 13.”

The FDA also wants the circulatory devices panel to consider better ways to construct future trials of similar devices and to come up with appropriate endpoints for a post-market surveillance study. The panel is scheduled to vote on whether the device is as safe and effective as surgery and whether its benefits outweigh its risks for the high-risk cohort.

https://www.massdevice.com/news/fda-possible-selection-bias-issues-confound-edwards-sapien-study?page=2

Medicare to Cover Edwards’ Sapien Heart Valve

On May 2, 2012 Mark Hollmer reported that for medical device companies, gaining Medicare reimbursement for surgical procedures involving their implants can be a sort of financial holy grail. After all, an implant won’t be used much if the cost can’t be covered. Edwards Lifesciences ($EW) has reached that point now that the Centers for Medicare & Medicaid Services has agreed to pay for surgery involving its Sapien transcatheter heart valve. Ssince Sapien’s U.S. debut in November. As a result, sales should get a boost, Wells Fargo analyst Larry Biegelsen said, as quoted by Bloomberg in its coverage of the news.

Specifically, CMS approved reimbursement of transcatheter aortic valve replacement therapy when the device is used to treat symptomatic aortic valve stenosis. The coverage determination is flexible and authorizes current and future FDA approved indications, the company notes, as well as coverage for clinical studies.

About 300,000 U.S. patients suffer from deterioration of the aortic heart valve, which forces the heart to work harder to pump blood, often leading to heart failure, blood clots and sudden death. More than half of patients diagnosed with the condition, called aortic stenosis, die within two years, according to the FDA. Every year about 50,000 people in the U.S. undergo open-heart surgery to replace the valve, which involves sawing the breastbone in half, stopping the heart, cutting out the old valve and sewing a new one into place. Thousands of other patients are turned away, deemed too old or ill to survive the operation.

The Sapien valve is usually threaded through the femoral artery via a small incision in the leg, and then guided up to the heart via catheter. An alternate procedure inserts the valve through a small incision between the ribs. The valve is then wedged into the aortic opening by an inflatable balloon, replacing the natural heart valve. The device is made from cow tissue and polyester supported by a steel frame.

Analysts estimate as many as 70,000 to 100,000 patients per year could eventually receive the valve. In the most recent quarter Edwards reported Sapien sales of $121.5 million, with the U.S. contributing $41 million. For the full year Edwards expects sales of $530 million to $600 million.

http://www.mercurynews.com/business/ci_20850361/fda-panel-backs-broader-use-edwards-heart-valve

eBook: Waiting for Guidelines Will FDA take the reins of laboratory-developed tests?

Two cardiac surgeons must independently evaluate the patient first, and hospitals offering the procedure must have an on-site heart valve surgery program, plus a cardiac catheterization lab or a lab/operating room hybrid with appropriate imaging systems. And as Bloomberg points out, the guidelines limit who can conduct the procedure to a multidisciplinary team of doctors that must include at least one heart surgeon and interventional cardiologist. And those experts must perform the surgery at least 20 times annually to remain certified.

CMS also requires the heart team and hospital to take part in a post-surgery clinical trial, a national registry that follows patients who have the procedure for at least one year. This study will look at variables including strokes, death, heart attacks, kidney injuries, any repeat procedures and overall quality of life.

Sapien, generated $41 million in sales during the first quarter, the first full quarter the device has been on the market.

http://www.fiercemedicaldevices.com/story/medicare-cover-edwards-sapien-heart-valve/2012-05-02?utm_medium=nl&utm_source=internal

June 13, 2012 – FDA panel votes in favor of Sapien valve. The FDA’s Circulatory System Devices Committee gave Edwards Lifesciences ($EW) a win Wednesday with a vote recommending the devicemaker’s Sapien transcatheter heart valve after an epic session. The panel voted 9-0–with one member abstaining–that the device’s benefits outweighed its risks, 7-3 in favor of its safety, and 9-1 for its effectiveness. The FDA will make a decision on the valve at a later date.

Earlier in the week, the FDA released a report showing the valve, which can be implanted without major surgery, significantly reduced death rates versus standard therapy in people with severe aortic stenosis. However, there was a higher incidence of major strokes and major vascular events seen in the group receiving the Sapien valve in a study.

Indeed, neurological events represented a major issue in the meeting, as heartwire notes, with several panel members pointing out that older, frail patients are far more concerned about strokes than death. Furthermore, mortality reduction with TAVI is, as the FDA terms it, impressive, but most treated patients die within two years. That said, panel members concluded that the benefits of transcatheter valve replacement in these frail patients offset the stroke risk.

“We are pleased with the panel’s strong recommendation for approval, and would like to thank them for their comprehensive and thoughtful review of the data presented from The PARTNER Trial. This represents another important step on the path to what we hope will lead to FDA approval of SAPIEN,” Michael Mussallem, Edwards’ chairman and CEO, says in a statement. “We would also like to thank the principal investigators and their heart teams at the PARTNER hospitals for their dedication to this clinical trial, and to their patients for participating in a study of a new therapy.”

Edwards has marketed Sapien in Europe since 2007 and could start selling it in the U.S. in Q4, 2012. Analysts note the worldwide market for heart valves could ultimately grow to $2 billion in annual sales, as the Orange County Business Journal reports.

http://www.fiercemedicaldevices.com/story/fda-panel-votes-favor-sapien-valve/2011-07-20

The valve SAPIEN is currently approved for patients who aren’t healthy enough to undergo the more invasive open-heart surgery, which has been used to replace the aortic valve for decades. On June 13, 2012 – the implant is approved for patients who are healthier, but still face serious risks from chest-opening surgery. Many such patients are in their 80s and have complicating medical factors like diabetes.

Irvine, Calif.-based Edwards plans to conduct two follow-up studies to evaluate long-term safety as well as differences in gender outcomes per FDA panel on June 13, 2012.

Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430N)

The Centers for Medicare & Medicaid Services (CMS) covers transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) with the following conditions described in

http://pharmaceuticalintelligence.com/2012/06/19/the-centers-for-medicare-medicaid-services-cms-covers-transcatheter-aortic-valve-replacement-tavr-under-coverage-with-evidence-development-ced/

CONCLUSIONS

The Pay for Performance Philosophy at Edwards Lifesciences will support a substantial reward for the Chairman and CEO in 2012. His $5.8 Million in total compensation in 2011, occurred for a average of Five Year Total Stockholders Return of 301% while at the same time S&P delivered an anemic Five Year Total Stock Return of 89% per 2011 Edwards Most Recent Return: -11.8%, 42 percentile as reported in 2011 Edwards Annual Report. With the potential of EW symbol exceeding $100 per share in the second half of 2012, CEOs total compensation may move Edwards from the 36 percentile to the median in the Comparator Group selected for determination of Executive compensation at Edwards. . In the most recent quarter Edwards reported Sapien sales of $121.5 million, with the U.S. contributing $41 million. For the full year Edwards expects sales of $530 million to $600 million.

FDA’s broadening definition of patients eligible for TAVR to include other patients than the ones with aortic stenosis that can’t undergo open heart surgery, will have an immediate effect on the total cost that these procedures will bear by having the procedure been covered by Medicare and Medicaid. An increase in the Healthcare cost and its National burden is expected. Analysts estimate as many as 70,000 to 100,000 patients per year could eventually receive the valve.

The Procedure will have a major improvement in the quality of life of patients undergoing TAVR with a favorable impact on their longevity.

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Investigational Devices: Edwards Sapien Transcatheter Aortic Heart Valve Replacement Transfemoral Deployment

Posted in Frontiers in Cardiology and Cardiovascular Disorders, Medical Devices R&D and Inventions, Valves & Tools, tagged Aortic valve, Aortic valve stenosis, Cardiac surgery, Edwards SAPIEN, Heart valve, Valve replacement on June 10, 2012| 7 Comments »

Reporter: Aviva Lev-Ari, PhD, RN

Cohort A of the PARTNER (Placement of AoRTic traNscatheterER valves) Trial is designed for patients with severe calcific aortic stenosis who are considered to be high-risk for conventional open-chest valve replacement due to the risk surgery might pose to them. These patients may be eligible to participate in a new, investigational transcatheter valve replacement procedure that is performed without

http://www.edwards.com/products/investigationaldevices/Pages/SapienTHV.aspx

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Investigational Devices: Edwards Sapien Transcatheter Aortic Valve Transapical Deployment

Posted in Frontiers in Cardiology and Cardiovascular Disorders, Medical Devices R&D and Inventions, Valves & Tools, tagged Aortic valve, Aortic valve stenosis, calcific aortic stenosis, Cardiac surgery, Edwards SAPIEN, health, Heart valve, Investigational device, Medtronic, Valve replacement on June 4, 2012| 8 Comments »

Reporter: Aviva Lev-Ari, PhD, RN

The Edwards SAPIEN transcatheter heart valve is an investigational device which is placed either through a transfemoral (RetroFlex 3 Transfemoral Delivery System) or transapical (Ascendra Transapical Delivery System) approach. The Edwards SAPIEN valve is being evaluated in the treatment of patients with severe calcific aortic stenosis who are considered to be high-risk for conventional open-heart valve replacement surgery.Cohort A of the PARTNER (Placement of AoRTic traNscatheterER valves) Trial is designed for patients with severe calcific aortic stenosis who are considered to be high-risk for conventional open-chest valve replacement due to the risk surgery might pose to them. These patients may be eligible to participate in a new, investigational transcatheter valve replacement procedure that is performed without

http://www.edwards.com/products/investigationaldevices/Pages/SapienTHV.aspx