trans-catheter aortic valve implantation should we all be doing this? dr philip maccarthy bsc phd...
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Trans-catheter Aortic Trans-catheter Aortic Valve ImplantationValve Implantation
Should we all be doing this?Should we all be doing this?
Dr Philip MacCarthy BSc PhD FRCPDr Philip MacCarthy BSc PhD FRCP
Consultant CardiologistConsultant Cardiologist
King’s College Hospital, London, King’s College Hospital, London, UK.UK.
BCIS Autumn Meeting, Crewe Hall, Crewe, September 26th 2008
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Otto et al N Engl J Med 1999;341:142–7
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Is there an unmet need?Is there an unmet need?
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(SCTS 5(SCTS 5thth Blue Book Blue Book 2002003)3)
AVR has become more AVR has become more common in the elderlycommon in the elderly
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Is there an unmet need?Is there an unmet need?
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What do we currently What do we currently have to offer?have to offer?
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Trans-catheter aortic valve Trans-catheter aortic valve implantationimplantation
CoreValve ‘Revalving’ systemCoreValve ‘Revalving’ system – – trans-femoraltrans-femoral
Edwards Sapien™ prosthesisEdwards Sapien™ prosthesis Trans-femoral (using the ‘RetroFlex’ Trans-femoral (using the ‘RetroFlex’
catheter)catheter) Trans-apical (using the ‘Ascendra’ Trans-apical (using the ‘Ascendra’
catheter)catheter)
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CoreValve ‘ ReValving’ CoreValve ‘ ReValving’ SystemSystem
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Edwards Sapien™ Edwards Sapien™ Trancatheter Heart Valve Trancatheter Heart Valve
prosthesisprosthesis
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What are the challenges What are the challenges of setting up a TAVI of setting up a TAVI
programme in the real programme in the real world?world?
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King’s College Hospital King’s College Hospital ExperienceExperience
35 patients treated with the 35 patients treated with the Edwards deviceEdwards device 17 Trans-femoral17 Trans-femoral 18 Trans-apical18 Trans-apical
First 17 of these as part of the First 17 of these as part of the PARTNER-EU study, PARTNER-EU study,
Next 18 in the SOURCE registryNext 18 in the SOURCE registry
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King’s College Hospital King’s College Hospital ExperienceExperience
20 women (57%)20 women (57%) Mean age - 83.9yrsMean age - 83.9yrs Mean Log Euroscore - 20.3 Mean Log Euroscore - 20.3
(porcelain aorta)(porcelain aorta) Mean peak AV gradient - 85.8mmHgMean peak AV gradient - 85.8mmHg Mean AVA - 0.61cmMean AVA - 0.61cm22
Median LOS - 8 daysMedian LOS - 8 days In-hospital mortality - 2 (5.7%)In-hospital mortality - 2 (5.7%)
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Patient work-upPatient work-up Lung/renal function testsLung/renal function tests Carotid DopplersCarotid Dopplers CT aorta – without contrastCT aorta – without contrast Trans-thoracic echoTrans-thoracic echo
Morphology of AV – peak/mean grad + Morphology of AV – peak/mean grad + AVAAVA
Dimensions of AV annulusDimensions of AV annulus Morphology of septumMorphology of septum Presence/mechanism of MRPresence/mechanism of MR LV systolic functionLV systolic function PAP if possiblePAP if possible
TOE – if annulus 24mm or greaterTOE – if annulus 24mm or greater
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Patient work-upPatient work-up
Cardiac CatheterisationCardiac Catheterisation Coronary angiogramCoronary angiogram RH cath with PAPRH cath with PAP Aortogram (PA or LAO) – 30ml @ Aortogram (PA or LAO) – 30ml @
15ml/sec15ml/sec Iliofemoral angiogram – 30ml @ Iliofemoral angiogram – 30ml @
6ml/sec6ml/sec No angioseal!No angioseal!
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The TeamThe Team
Dedicated Anaesthetist(s)Dedicated Anaesthetist(s) EchocardiologistEchocardiologist PerfusionistPerfusionist Surgical scrub nurseSurgical scrub nurse Cath lab scrub nurseCath lab scrub nurse Surgeon(s)Surgeon(s) Interventional Cardiologist(s)Interventional Cardiologist(s) The Company (for valve crimping)The Company (for valve crimping)
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Fluoro
Cardio
CT Surg
Cath lab kit
Valve crimping
Surgicalkit
Echo Machine
Echo
CP bypass
Anaes. Machine
Anaes
Nurse
Screens
Nurse
Rad
Tech
ODA
Rep
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The Learning CurveThe Learning Curve
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Trans-femoral pAVRTrans-femoral pAVR
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TF Valve deploymentTF Valve deployment
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Trans-apical pAVRTrans-apical pAVR
A higher risk patient A higher risk patient groupgroup
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TA valve deploymentTA valve deployment
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The importance of peri-The importance of peri-procedural imagingprocedural imaging
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Stenosed native aortic Stenosed native aortic valvevalve
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Guidewire across native Guidewire across native AVAV
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Valve deploymentValve deployment
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Edwards Sapien valve in-Edwards Sapien valve in-situsitu
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Potential peri-procedural Potential peri-procedural complicationscomplications
Vascular accessVascular access Passage of introducer sheath Passage of introducer sheath Surgical repair Surgical repair Iliac dissection/rupture Iliac dissection/rupture
Balloon valvuloplastyBalloon valvuloplasty Aortic regurgitationAortic regurgitation CHB on background of RBBBCHB on background of RBBB
Valve deploymentValve deployment Occlusion of coronary ostiaOcclusion of coronary ostia Displacement of prosthesisDisplacement of prosthesis
Rapid pacingRapid pacing OtherOther – –
Interference with the mitral valveInterference with the mitral valve CVACVA
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Failed femoral accessFailed femoral access
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Iliac balloon occlusionIliac balloon occlusion
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Occlusive iliac dissectionOcclusive iliac dissection
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Iliac artery rupture…Iliac artery rupture…
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……repaired with a covered repaired with a covered stentstent
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The importance of case The importance of case selectionselection
Patients with advanced pulmonary Patients with advanced pulmonary disease may do better with a TF disease may do better with a TF approachapproach
Poor LV systolic function - less room Poor LV systolic function - less room for errorfor error
The aetiology of depressed LV The aetiology of depressed LV function and MRfunction and MR
Beware RBBBBeware RBBB
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So should we all be doing So should we all be doing it?it?
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Some words of cautionSome words of caution The precise need is The precise need is
unknownunknown
There is currently no long-There is currently no long-term dataterm data
Funding issues remain a Funding issues remain a problemproblem
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So should we all be doing So should we all be doing it?it?
At the moment NOAt the moment NO - because: - because: Experience should be concentrated in major Experience should be concentrated in major
centrescentres New centres should be closely proctoredNew centres should be closely proctored Centre must have:-Centre must have:-
Experienced cardiac anaesthetistsExperienced cardiac anaesthetists Cardiopulmonary bypass facilityCardiopulmonary bypass facility Excellent imaging abilityExcellent imaging ability Dedicated cardiac ITU/recovery areaDedicated cardiac ITU/recovery area
Long-term data/a solution to funding is Long-term data/a solution to funding is neededneeded
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AcknowledgementsAcknowledgements King’s TAVI TeamKing’s TAVI Team:-:-
CT SurgeonsCT Surgeons - Olaf Wendler & - Olaf Wendler & Ahmed El-GamelAhmed El-Gamel
CardiologistsCardiologists – Phil MacCarthy & – Phil MacCarthy & Martyn ThomasMartyn Thomas
EchocardiologistEchocardiologist – Mark – Mark MonaghanMonaghan
AnaesthetistsAnaesthetists – Emma Alcock & – Emma Alcock & Kailasam RajagopalKailasam Rajagopal
Research Sister/Co-ordinatorResearch Sister/Co-ordinator – – Karen Wilson/Beth BrickhamKaren Wilson/Beth Brickham
Other cath lab/theatre staff Other cath lab/theatre staff involvedinvolved