Andrew Chukwuemeka MD FRCSAndrew Chukwuemeka MD FRCSConsultant Cardiothoracic SurgeonConsultant Cardiothoracic Surgeon

Hammersmith HospitalHammersmith Hospital

Imperial College Healthcare NHS TrustImperial College Healthcare NHS Trust

Less Invasive Aortic Valve SurgeryLess Invasive Aortic Valve Surgery

SCTS BrightonSCTS Brighton 19th March 201319th March 2013

• TAVI

• New valves

• Sutureless, “rapid deployment”, AVR

• Incisions

• Mini-sternotomy / mini-thoracotomy

• Mini-CPB

Less Invasive Aortic Valve SurgeryLess Invasive Aortic Valve Surgery

Aortic valve surgery in the UKAortic valve surgery in the UK

Is this safe?

Valve Surgery in Octogenarians: A Safe Option with Good Medium-Term Results

Andrew Chukwuemeka, Michael A. Borger, Joan Ivanov, Susan Armstrong, Christopher M. Feindel, Tirone E. David

Division of Cardiovascular Surgery, Toronto General Hospital andDepartment of Surgery, University of Toronto

Conclusion : Valve surgery in selected octogenarians is associated with low morbidity and mortality. The ou tlook after surgery is very good, and surgery should not be denied to this group on the basis of age alone.

The Journal of Heart Valve Disease

2006;15:191-196

Euro Heart SurveyA prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease.Eur Heart J 2003 Jul;24(13):1231-43

1 in 3 patients with severe symptomatic AS did not have surgery

Unmet need in severe ASUnmet need in severe AS

• Charlson E et al. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis 2006;15:312-321

• Iung B et al. A prospective survey of patients with valvular heart disease in Europe:The Euro Heart Survey on Valvular Heart Disease.

European Heart Journal 2003;24:1231-1243

• Bouma B J et al. To operate or not on elderly patients with aortic stenosis:the decision and its consequences. Heart 1999;82:143-148

60%60%

32%32%

41%41%

Unmet need in severe ASUnmet need in severe AS

• Charlson E et al. Decision-making and outcomes in severe symptomatic aortic stenosis. J Heart Valve Dis 2006;15:312-321

• Iung B et al. A prospective survey of patients with valvular heart disease in Europe:The Euro Heart Survey on Valvular Heart Disease.

European Heart Journal 2003;24:1231-1243

• Bouma B J et al. To operate or not on elderly patients with aortic stenosis:the decision and its consequences. Heart 1999;82:143-148

60%60%

32%32%

41%41%

TAVI is a much needed alternative to TAVI is a much needed alternative to conventional AVRconventional AVR

What is TAVI (R)?

Less Invasive Aortic Valve Surgery Less Invasive Aortic Valve Surgery -- TAVITAVI

Access routes :– Transfemoral

– Transapical– Direct aortic

– Subclavian (axillary)– Iliac

– +/- conduit

Depends on: Depends on: •• patient anatomypatient anatomy

•• team preference team preference

•• experienceexperience

Ann Thorac Surg. 2005 May;79(5):1812-8

Multidisciplinary approach

“Heart Team”

TAVI team• Cardiac surgeons

• Interventional cardiologists• Imaging cardiologists

• Radiologists• Elderly care physicians

• Anaesthetist• Critical care physicians

• Specialist nurses

• Physiotherapists• Occupational therapists

• Rehabilitation• Perfusionists

• Operating theatre team• Psychologists

TAVI – patient selectionAnatomically suitable, inoperable or very Anatomically suitable, inoperable or very highhigh --risk, severe symptomatic ASrisk, severe symptomatic AS

– Elderly (but not exclusively)– Co-morbidities

• respiratory, renal, poor LV, hepatic ++++

– Contraindication to AVR• porcelain aorta, mediastinal radiation

– Risk score (STS >10%, EuroSCORE >20%)

– Frailty

Frailty in TAVIFrail Patients Are at Increased Risk for Mortality and ProlongedInstitutional Care After Cardiac Surgery. Circulation 2010;121:973-8

• Complex interaction between age and chronic illness• Chronological age is not the same as biological age• Subjective

• Parameters:– gait, 5m walk speed, grip strength, ADL, biological markers (albumin,

bilirubin, lung function tests), +++

Frailty in TAVI

Risk scoring in TAVI

Risk scoring in TAVI

TAVI RESULTS – PARTNER B

PARTNER B - NYHA

PARTNER A: UPDATE – 2 year results

PARAVALVULAR LEAK

PARTNER A: UPDATE – 2 year results

The future of TAVI?

• Improving patient selection (“picking the winners”)

• Improving technology (access, paravalvular leak, stroke)

• Adhering to established principles (durability etc.)

Major Dwight Harken – US Army

• 133 consecutive survivors

• First series of successful “open heart” operations

•It must not propagate emboli•It must be chemically inert and not damage blood elements•It must offer no resistance to physiological flows•It must close promptly

•It must remain closed during the appropriate phase of the cardiac cycle•It must have lasting physical and geometric features•It must be inserted in a physiological site•It must not annoy the patient•It must be capable of permanent fixation•It must be technically practical to insert

““A device is safe when it is safer than A device is safe when it is safer than the condition it correctsthe condition it corrects””

Ten Commandments Ten Commandments -- Dwight HarkenDwight Harken

Sutureless AVR:New valve technologyNew valve technology

Ready to implantAs supplied

Valve collapsingValve collapsed to a

reduced diameter (not crimped)

Dedicated tools facilitate visibility at the implant site and Dedicated tools facilitate visibility at the implant site and Dedicated tools facilitate visibility at the implant site and Dedicated tools facilitate visibility at the implant site and accurate valve positioningaccurate valve positioningaccurate valve positioningaccurate valve positioning

Collapsed

Perceval S

PERCEVAL S PERCEVAL S –– sutureless AVRsutureless AVR

Sutureless AVR Sutureless AVR -- Potential benefitsPotential benefits

•• Ease of implantation resulting in a shorter crossEase of implantation resulting in a shorter cross--clamp and clamp and cardiopulmonary bypass timecardiopulmonary bypass time

•• HighHigh--risk risk –– comorbidities, advanced age comorbidities, advanced age •• Concomitant cardiac proceduresConcomitant cardiac procedures

•• Adhere to established surgical principles (unlike TAVI)Adhere to established surgical principles (unlike TAVI)

•• Annular decalcification (emboli, paravalvular leak)Annular decalcification (emboli, paravalvular leak)•• Direct visionDirect vision

Ready to implant

2-Step Deployment & Balloon Dilatation

Valve is collapsed to a reduced

diameter

Valve deployment Implant

Valve is positioned in aorta

IMPLANTATIONIMPLANTATION

IMPLANTATIONIMPLANTATION

Sutureless AVR Sutureless AVR ––HAMMERSMITH EXPERIENCEHAMMERSMITH EXPERIENCE

TotalTotal

n=17n=17

AgeAge

Range: 76 Range: 76 –– 9090

Mean: 85.6 yrs +/Mean: 85.6 yrs +/-- 5.95.9

GenderGender

Female: 6 (35%)Female: 6 (35%)

Male: 11 (65%)Male: 11 (65%)

Logistic EuroscoreLogistic Euroscore

Range: 9.76 Range: 9.76 –– 49.7549.75

Mean: 20.9 +/Mean: 20.9 +/-- 13.813.8

•• ProcedureProcedure

•• AVR only AVR only –– 12 (61%)12 (61%)

•• AVR + CABG AVR + CABG –– 5 (29%)5 (29%)

•• Valve SizesValve Sizes

•• S S –– 55

•• M M –– 88

•• L L –– 44

•• Bypass TimeBypass Time

•• Range: 49 Range: 49 –– 77min77min

•• Mean: Mean: 59.4min59.4min +/+/-- 11.611.6

•• CrossCross--clamp Timeclamp Time

•• Range: 27 Range: 27 –– 58min58min

•• Mean: Mean: 44.1min44.1min +/+/-- 10.410.4

Sutureless AVR Sutureless AVR ––HAMMERSMITH EXPERIENCEHAMMERSMITH EXPERIENCE

Sutureless AVR Sutureless AVR ––HAMMERSMITH EXPERIENCEHAMMERSMITH EXPERIENCE

Minimally-invasive aortic surgery

Minimally-invasive AVR

Brown et al. JTCVS March 2009

Ministernotomy versus conventional sternotomy for aortic valve replacement: A systematic review and meta-analysis.

Morgan L. Brown, MD, Stephen H. McKellar, MD, Thoralf M. Sundt, MD, and Hartzell V. Schaff, MD

Conclusion: Ministernotomy can be performed safely for aortic valve replacement, without increased risk of death or other major complication; however, few objective advantages have been shown. Surgeons must conduct well-designed, prospective studies of relevant, consistent clinical outcomes to determine the role of ministernotomy in cardiac surgery.

Marginal benefit wrt mortality, ICU stay.Longer CPB and XC time

Patient choiceCosmesis

Cardiopulmonary bypass

• Cardioplegic arrest in diastole

• Bloodless operative field

• Detrimental effects of extracorporeal circulation

• Risks vs. benefits

Miniature Cardiopulmonary Bypass

1. Optimise venous drainage2. Minimise microair3. Minimise surface contact4. Minimise blood damage5. Minimise haemodilution

Optimise Venous Drainage

• Controlled Kinetic Venous Drainage• Smaller cannula – 29 French• Many draining holes• Holes set into grooves• Long cannula• Improves Liver/ GIT drainage?

Minimise Microair

Active rather than Passive air removal

300ml/min – 5sec

120µ filter

Pump flow

Perthel M, El-Ayoubi L, Bendisch A, Laas J, Gerigk M. Clinical advantages of using mini-bypass

systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo

clinical perspective. Eur J Cardio-thorac Surg 2007;31:1070-75.

Minimise Surface Contact

Oxygenator is the largest non-physiological surface in CPB circuit

1.8m2 Gas Exchange Surface Area 1.1m2 Gas Exchange Surface Area

Minimise Blood Damage

Well Managed Suction/Vent Blood (↓ Air

Mixing and -P)

Poorly Managed Suction/Vent Blood (↑ Air

Mixing and -P)

Minimise Haemodilution

Patient Specific Volume StrategyNOT

Volume Restrictive

Retrograde Autologous Prime Antegrade Autologous Prime

• TAVI

• New valves

• Sutureless, “rapid deployment”, AVR

• Incisions

• Mini-sternotomy / mini-thoracotomy

• Mini-CPB

Less Invasive Aortic Valve SurgeryLess Invasive Aortic Valve Surgery

““In times of change, the learners inherit the Earth In times of change, the learners inherit the Earth while the learned find themselves beautifully while the learned find themselves beautifully equipped to deal with a world that no longer equipped to deal with a world that no longer exists.exists.””