 Thank you for this introduction. My name is Vaughn Rickrazier. I'm an interventional cardiologist at Texas Heart Institute and CHI Health, Baylor St. Luke's Medical Center. I'm also program director of peripheral vascular introspection at Texas Heart Institute and Baylor College of Medicine in Houston, Texas. The title of my presentation is TAVR versus surgical aortic valve replacement and and the survival, hemodynamics, bioproesthetic valve deterioration and long-term outcomes and the need for re-intervention. As far as my disclosures are concerned, I'm on the Speaker's Bureau for Metronic. So what is the currently available percutaneous valve that are available, so-called TAVR? When Metronic Evolute Pro is self-expanding valve that we can see on the left-hand side and Edward Sapien, the 3-valve is a balloon-expanding valve and more recently there was a device that was approved, Abitovascular Portico device that's also self-expanding valve. Now when we look through the history of different clinical trials, we can see as far as the core valve is concerned, there was extreme risk study and as far as all-cause mortality is concerned, we can see it from 2011. Then the next generation was Evolute R-valve that in comparison with the surgical outcomes in high-risk patients, we can see that in yellow line the surgical mortality was higher than with the percutaneous Evolute R-valve. Followed that, a new valve was introduced to Evolute Pro and that was studied in intermediate-risk patients in comparison with surgical approach and we can see the results are very similar at two years follow-up. Finally, the more recent so-called low-risk trial with Evolute Pro plus a valve, comparing the surgery to TAVR and we can see that surgery had slightly higher mortality and slightly similar stroke rate at 20 for a month of follow-up. Now, limited data exists on the incidents and factors that are associated with structural valve deterioration after TAVR and also after surgery from a large-scale multi-center and randomized clinical trials. However, previous work demonstrated that early generation intravalvella or balloon expandable bioprostesis have significantly higher five-year rates of a structural valve deterioration in comparison to surgery, whereas newer-generational annular valves have similar structural valve deterioration rates, as we can see here in this particular diagram at five years of follow-up, where the sapon XT was the early generation balloon expandable valve with a 9.5% mortality of five years and a newer generation sapon III had significantly lower mortality of 3.9 and surgery is mortality at five years with 3.5%. Now, prior analysis have shown that the TAVR with supranular self-expanding bioprostesis such as Evolute R and Evolute Pro had significantly lower hemodynamic valve deterioration or re-interaction due to stenosis than surgical valve repair. And this has been shown in a notion eight-year follow-up study. Core valve versus SAVR as far as bioprostatic valve failure is concerned where at eight years of follow-up SAVR's biologic valve failure was occurring in 10.6% of patients versus only in 7.3% of patients that had a core valve procedure. As far as hemodynamics are concerned, when we look at the late mean gradients after core valve versus surgery and five-year follow-up in cardiovascular high-risk patients, we can see that the effective orifice area for core valve is shown in blue, was larger than with surgery. And as far as mean gradient was concerned, again on the right side, we can see that it was also larger with core valve than with surgery. Meaning that core valve performs well and better as far as effective orifice area is concerned and also as well as mean gradient is concerned at five years of follow-up. Now, that is also available for balloon expandable valve from the choice trial that was carried on in Europe, in Germany, and we can look at the late mean gradients comparing core valve versus sapient valve. And we can see that the gradients at five-year follow-up shown for core valve in blue are significantly lower or almost half of what they were with a sapient XT valve. That was a previous generation sapient valve. The comparison of sapient self balloon expandable valve versus evolut self-expanding valve are shown in this particular study that was published by Ring in American Journal of Cardiology in 2020. We can see as far as echo measurements are concerned at one one follow-up, the gradient was significantly lower for evolut valve than for sapient. And when we look at mean gradient higher of 20 millimeters of mercury, which is significant, again was significantly lower for evolut than for sapient. And when we look at one-year follow-up, again similar findings were observed for better outcomes with evolut than with sapient. On the right-hand side, we can see again, as far as mean gradients are concerned, they were significantly lower in comparison with sapient valve as we can see here as well. In this particular study from Australia, as far as one-year mortality is concerned, we can see that impaired valve hemodynamics at one-year follow-up showed definite effect as far as the risk and mortality is concerned and there was a significantly higher mortality in patients with severe impaired valve hemodynamics than in patients with normal or mildly impaired valve hemodynamics at one-year follow-up. Now as far as additional data related to structural valve deterioration in patients that undergo TAVR versus SAVR merits further evaluation. And recent analysis that was presented at ACC meeting in March of 2022 looked at this particular aspect and the study objective included a core valve evolut pooled data analysis to evaluate five-year incidents outcomes and predictors of hemodynamic structural valve deterioration in patients undergoing supranular self-expanding TAVR and surgery from the core valve U.S. Pivotal and Sir TAVR trials. And what we can see here at five-year follow-up in patients that had a larger than larger than 23 millimeter annulus again significantly higher structural valve deterioration with surgery than with TAVR. And this was particularly true for patients that had smaller orifices such as patients that had a very small annulus of less than 23 millimeters but it was also important for patients that had larger annular. Now, when we look at core valve pooled data analysis as far as predictors concern for both surgery and also TAVR we can see that in pooled randomized trial for TAVR the all cause mortality was higher when structural valve deterioration occurred also cardiovascular mortality was higher need for hospitalization for aortic valve related conditions was higher and the composite assessment was higher. This was also true for surgical valves as well as we can see further down and it was true for all TAVR valves for all variables included. Now additionally the univariate and multivariate predictors were analyzed and all the patients fared better as far as structural valve deterioration is concerned rather than younger patients and male patients fared better than female patients and this obviously had to do something with the annular size. The body surface area was a negative predictor. It means causing more structural valve deterioration. The larger the body surface area the highest of structural valve deterioration is concerned. Patients that had a prior coronary intervention and also patients that had a prior atrial fibrillational flutter had lower structural valve deterioration. A potential explanation for those two findings are that patients that are treated for coronary heart disease and prior intervention and patients that are treated for atrial fibrillation and flutter require more aggressive antiplatelet and anti-correlation therapy than are normally given to patients after TAVR. Now one of the great concerns after TAVR procedure is the incidence of and significance of patient prosthesis mismatch. It means that the prosthesis that is used is either too small or too large or it's under expanded or it's overexpanded. And this was particularly true in the so-called WIN TAVI trial which is women's international registry and we can see as far as predictors of patient prosthesis mismatch is concerned in this particular study it occurred roughly in 36 percent of patients which is quite concerning. This was more common for smaller valves less than 23 millimeters that occurred roughly in 50 percent of patients and particularly true for balloon expandable valves which again occurred in 43.5 percent of patients. However patients with self-expanding valve had significantly lower incidence of prosthesis patient mismatch as is shown in a blue graph. Now as far as subclinical leaflet thrombosis and reduced leaflet motion or so-called halt or thrombosis of the valve is concerned obviously this finding carries quite concerning and in certain instances quite concerning consequences. In surgical literature the incidence of halt or silent leaflet thrombosis in surgical bioprostesis occurs is somewhere between 0.8 to 4 percent of patients. However post-tabber halt ranges significantly between 4.5 to 40 percent depending on the publication. Now more recently FDI has expressed concerns and have called for prompt attention to this clinical problem. The images on the CT on the left-hand side and also on the right-hand side in diastole and systole are shown with patients that have limited valve leaflet motion or thrombosis. Now in this particular study that was published American Journal of Cardiology in 2020 as far as halt is concerned comparing a tabber versus a surgery at 30 days and also at one year we can see that at 30 days the incidence was similar for both for surgery and percutaneous valve deployment somewhere in the range between 60 to 70 percent of patients. Most of those were so-called mild halt or a certain degree of moderate halt and at one year of follow-up the numbers were higher. There was statistically no significant difference between saber and tabber and as we can see most of the tabber patients had a relatively mild degree of halt and significantly lower degree of halt than with surgery. Now more recently Dr. Popma presented at the ACC meeting in 2020 results with evolut data as far as a more than 50 percent halt which is quite concerning halt and we can see at 30 days it was a little bit higher with the saber than tabber. However at one year follow-up it was higher in saber patients than in tabber patients. Now as far as partner three and sapien data data is concerned saber versus a tabber is concerned in subclinical leaflet thrombosis we can see that with sapien three at 30 days the occurrence was roughly occurring in 13 percent of patients and in surgery significantly lower in 5 percent of patients. At one year of follow-up the incidence of halt was similar in both sapien and surgical group occurring between 20 to 28 percent of patients. One of the concerns as far as tabber is concerned treatment of patients with bicuspid aortic valve with a tabber. Here we can see various degree of complications as far as bicuspid aortic valve is concerned. It can be present with no raffae present with non-calcified raffae or patients that have fused raffae and severe calcifications. The new classification that's shown on the right-hand side we can see from no calcification to a severe calcification of infusion of raffae. We can see that patients with more advanced disease and severe fusion and calcification have dramatically higher mortality at two or three years of follow-up. One of the main detriment as far as tabber is concerned with self-expanding and also with balloon expanding valves are concerned calcification in the left ventricular outflow as well as calcification of the annulus and the valve leaflets and less than optimal outcomes related to aortic regurgitation as is shown here. There are numerous studies that have been published related to bicuspid aortic valve related to tabber procedure with both balloon expandable and self-expandable valve as we can see here in the study by forest and all that look at the evoluted self-expanding valve. There was evidence of more need for re-intervention in balloon expandable valve. There was no difference in mortality's concern or stroke or coronary obstruction or patient prosthesis mismatch or any changes in hemodynamics is our concern. Now in a MacArthur study that studied the sapien 3 balloon expandable valve stroke was somewhat higher at 30 days and also at one years with balloon expandable valve but no difference in mortality or gradients or perivalvular leak. And we can see in another study in that was published in the journal of cardiovascular imaging in relatively small number of patients that at 30 days there was no difference in mortality or stroke or patient or pacemaker or gradients needed. In the study comparing sapien 3 and evolut are concerned we can see in the last study shown here on the bottom with a follow-up at 30 days and one year that bicasperiortic valve had higher risk of conversion to surgery need for second valve implant high incidence of perivalvular leak and need for re-intervention for device failure. There was no difference in mortality or stroke or perivalvular leak between balloon expandable versus self-expandable valve. Balloon expandable valves had lower rate of second valve and a need for a permanent pacemaker but had higher rate of annular rupture. So in conclusion, the supra annular family of TAVR devices provides better acute valve performance and larger effective orifice areas than surgical bioprostesis. Acute valve performance such as gradient effective orifice area or patient prosthesis mismatch was statistically better with supra annular TAVR than surgery up to eight years of follow-up than after aortic valve replacement. The supra annular valve has less hemodynamic valve deterioration than SAVR at five years after aortic valve replacement and intra annular balloon expandable TAVR has similar or higher rates of structural valve deterioration and bioprostatic valve failure compared to SAVR. However, additional longer-term studies are needed to compare intra annular TAVR to supra annular TAVR for long-term outcomes. There are ongoing studies in patients with TAVR after SAVR for smaller annular such as aortic area of 43 millimeters square annular and also in women that have a smaller annular to determine the implications of acute hemodynamic performance and long-term outcomes. Thank you very much for your attention.