presentación de powerpoint - solaci · total number of valves implanted by size, 2011-2014...
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Genero: Masculino Edad: 80 años Peso: 73 kg Estatura: 1.70 mts BMI: 25.2
Antecedentes:1. DM, HTA, ERC, EPOC, FA.2. INSUFICIENCIA VALVULAR AORTICA SEVERA.3. ICC CON FEVI 45%
Clínica: NYHA III/IV E ICC DESCOMPENSADA
CASO N°1:
STS Score:Mortalidad: 7.27%Morbimortalidad: 28.81%
Coronariografía:
Ventriculograma + Aortograma:
Ecocardiograma:
Ecocardiograma:
MECANISMOS Y ETIOLOGIAS DE LA INSUFICIENCIA
AORTICA
Cúspides anómalas o
perforadas
Endocarditis
Enfermedad Reumática reumatoide
Espondilitis Anquilosante
Dilatación de la raíz
Aortica con mala
coaptación de las
cúspides
Espondilitis Anquilosante
Enfermedad Reumatoide
Sífilis
Ehlers-Danlos
Pseudoxantomas elásticos
Falta de soporte en las
comisuras con
deficiente coaptación
de las cúspides
aorticas
Tetralogía de Fallot
Defecto del septo Ventricular
Disección de Aorta
Aortitis
Trauma
Etiology of Aortic Regurgitation
SEVERE AI SECONDARY TO LVADIMPLANTS INCREASING
EXPONENTIALLY.
MSCT:
MSCT: PERIMETRO 87 mm
Acceso Vascular Derecho:
Acceso Vascular Izquierdo:
JenaValve
SymetisValve
COREVALVE:
Total number of valves implanted by size, 2011-2014 Angiografía de Occidente S.A. Cali- Colombia. 2016
Center experience: Angiografía de Occidente S.A. registry, Cali-Colombia 2011-2014
(33%)
(15.5%)
(7.5%)
NO PPM
PPM: 120 LPM PPM: 140 LPM
RECAPTURA DE LA VALVULA
MCP 160 LPM
NUNCA LIBERAR SIN MARCAPASOS
PPM OFF
Outcomes According to Devices
Mortality and Post-
Procedural Aortic Regurgitation
Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017
All cause mortality predictors
STS Score
LVEF < 45%Mitral Regurgitation > Moderate at baseline
POST-PROCEDURAL AORTIC REGURGITATION > MODERATE
Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017
Predictors of ComplicationsEarly Vs Late Experience
Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017
• 72 años
• Mujer
Antecedentes:
• Artritis reumatoide severa
• FEVI: 30%
• 6 meses evolución falla cardiaca con progreso a estadio IV
• Endocarditis Marantica
CASO N°2:
MSCT: PERIMETRO 79mm
Evolut R 29
PPM: 120 LPM PPM: 140 LPM
PPM: 140 LPM PPM: OFF
NUNCA SUSPENDER ARREO CON MARCAPASOS EN EL MOMENTO DE LA LIBERACION DEFINITIVA
• 78 y.o STS: 8,5• Heart Failure• Degenerative Cerebral Disease (Mild to moderate)• Hypertension • Chronic Alcoholism• Echocardiogram:
• Severe Aortic Insufficiency IV/IV• EF: 35%
• Creatinine: 2.0
CASO N°3:
Aortic Regurgitation
18 19 20 21 22 23 24 25 26 27 28 29 30
56.5 62.8 72.3 81.7 94.2
23 mm 26 mm 29 mm 34 mm
Diameter (mm)
Perimeter (mm) †
Evolut R System
PERIMETRO: 95mm
Aortic Regurgitation
Angulo: 61°
No PPM PPM 130
PPM 150
Critical moment to release the device
Second Attempt
Third AttemptOscillatory Movements of the DeviceAumento de PPM a 170 lpm
Mantaining PPMEven after last 1/3 of reléase PPM
170
Final Result
Challenges in treatment of non-calcified AR
Insufficient anchoring
Dislocation / embolisation
Residual AR
Annular rupture
Concomitant aortic dilation
Large annuli
PHASES FOR DEVICE RELEASE
First Phase: Absence of Displacement, Peacemaker not needed (stable system).
No PPM PPM 130
First Phase: Should start peacemaker at 130 to 150 bpm.
BPM 150
Critical moment to release the
device
Second phase: Even with PPM 150 BPM the system hasn’t achieved annular contact with the annular system,
you can tell by the movement. Displacement should be avoided and Increase pacing at 170-180 BPM.
Third Phase: SPIN OFF Movement. At no-Recapture point the valve is still out of adequate
contact, and is still bound to migrate unless we increase the pulse rate. (BPM 160-180)
Fourth phase: No movement, achieved at rates between 180 - 200 BPM.
M, 75YO.
W: 75KG, H 172CMS, STS: 6,2% RISK.
5 months of functional class deterioration NYHA III.
ECHO:
• LVEF 53%, AV: SEVERE INSUFFICIENCY, CV:7mm. SPP:50mmHg.
• MV: Moderate Insufficiency.
CORONARY ARTERIOGRAPHY
• No coronary artery disease
• LVEF 50%
• AV: Severe Regurgitation IV/IV
CT:
• LVEF 49%, Diameter Min: 23,6mm Max. 28,7mm. Perimeter 86,5mm
CASO N°4:
ECHO
DIAGNOSTIC ANGIOGRAPHY
CORONARY
CT
Multiple Options for Vascular Access
Direct aortic
Subclavian/Axillary
Transapical
Transfemoral
Carotid
Common IliacRPA
IVC to Aorta Entry
Transeptal Supranavicular
Access Selection
Femoral Access
Left Axillary Access
Direct Aortic Access
Supra Aortic Arch Access
Trans-apical Access
PercutaneousLocal anesthesia
Surgical cut-downGeneral anesthesia
Surgical cut-downGeneral anesthesiaThoracotomy
Surgical cut-downGeneral anesthesiaThoracotomyVentriculotomy
Caval-Aortic Access
Trans Venous/Septal
- Femoral Vein
- Yugular Vein
Supranavicular Access
Carotid Access
Strategy
Subclavian access
Illiac Access
Subclavian Technique1.Surgical cut down
2.Place two (2) vessel loops around axillary artery
3.Place two (2) standard double purse-string sutures* and create an oval-shaped axillary artery access incision starting at downstream edge of purse-string sutures.
4.Use direct cannulation
Subclavian Technique
5.Advance 18 Fr introducer over super stiff guidewire
6.Position distal end of 18 Fr introducer immediately distal (upstream) to innominate/brachiocephalic artery
7.Full valve functionality and partial repositionability provide time for evaluation and adjustment.
8.Withdraw delivery catheter, remove introducer, and utilize purse-string sutures to maintain effective hemostasis.
Angle: 86°
AREA: 44 mm
Perimeter: 83,5mmArea: 54,5mm
DIAMETER: 15,4 cms2,89 cms
PROCEDURE
WIRE IN HORIZONTAL PLANE, NOT BELLY UP.
PULL BACK
LIBERACION CON PPM A 120
Gender: Male
Age: 64 y.o.
Weight: 68 kg
Height: 1.70 mts
Medical History:Severe Aortic Regurgitation
Coronary Artery Disease (Stent DA 2013)
HT
COPD
Peripheral Vascular Disease Aortic dissection type B
CHF
CKD (Creat: 1.65)
Symptoms: NYHA III/IV
STS Score:
Mortality: 9.42%
Euroscore: 10.48%
CASO N°5:
Gender: Male
Age: 72 y.o.
Weight: 74 kg
Height: 1.68 mts
Medical History: Severe Aortic Regurgitation
LV disfunction
HT
COPD
DM2
PPM 2016
CASO N°6:
Coronary Angiography, Ventriculogram and Aortogram
Valve Deformation During Snare