TAVR and Cardiac Surgeons

Transcription

1 TAVR and Cardiac Surgeons

2 TAVR and Cardiac Surgeons Ragheb Hasan Consultant and Clinical Lead Cardiothoracic Surgeon Manchester Royal Infirmary, Oxford Road, Manchester UK

3 Aortic Stenosis Is A Growing Problem! - many patients probably undiagnosed 3% at 75 years 5-10% at 85 years Prevalence >75 years old 100, ,000 in UK -Surgical AVR 5000 pa -TAVI 2000 pa Iung, B. & Vahanian, A. (2011) Epidemiology of valvular heart disease in the adult Nat. Rev. Cardiol. doi: /nrcardio

4 Natural History Survival after onset of symptoms is 50% at 2 years and 20% at 5 years 1 Surgical intervention for severe aortic stenosis should be performed promptly once even minor symptoms occur 1

5 Survival, % Worse than metastatic cancer Year Survival Breast Cancer Lung Cancer Colorectal Cancer Prostate Cancer Ovarian Cancer Severe Inoperable AS* *Using constant hazard ratio. Data on file, Edwards Lifesciences LLC. Analysis courtesy of Murat Tuczu, MD, Cleveland Clinic 5 year survival of breast cancer, lung cancer, prostate cancer, ovarian cancer and severe inoperable aortic stenosis 5

6 Patients undergoing surgical AVR do well Pai Ann Thorac Surg 2006

7 But many patients are turned down for surgery Vadajaran Ann Thorac Surg 2006 Iung EHJ

8 History of Trans-Catheter Aortic Valve Replacement Cribier et al. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? [Lancet 1986;1:63-7]. Anderson et al. Transluminal implantation of artificial heart valves. Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs. [Eur Heart J 1992;13:704-8]. Bonhoeffer et al. Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction. [Lancet 2000;356:1403-5].

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10 Transcatheter Aortic Valve Implantation A less invasive but more expensive alternative to conventional AVR in those deemed inoperable or high risk for conventional surgery

11 Cardiovascular Mortality (%) PARTNER - mortality halved Standard Rx (n = 179) TAVR (n = 179) 74.5% 80.6% 85.9% 62.4% 44.6% 57.3% 41.2% 47.6% 20.5% 30.7% Months

12 Mortality (%) As much benefit for patients >85 years and < 85 years 96.0% 91.8% 73.5% 70.4% Months

13 TAVI PROGRAMME IN MRI SINCE 2008 The Multidisciplinary Team: Cardiologist (TAVI Cardiologist) Cardiac Surgeon (TAVI Surgeon) TAVI Nurse Practitioner / Co-ordinator) Imaging Cardiologist Radiologist Cardiac Surgeon (non-tavi)

14 The Approaches Trans-femoral Trans-subclavian Trans-aortic Trans-apical Other less common approaches

15 The Surgeon s role We run a combined one stop TAVI clinic We receive referrals from cardiology, cardiac surgery and district general departments including inpatient urgent patients We assess the patients primarily for TAVI Some patients are considered for conventional surgery due to other co-existing valvular pathology or if the patients are deemed better off with conventional aortic valve replacement. Some patients are considered for off pump coronary artery bypass grafts and trans-aortic TAVI UK TAVI Trial

16 The Surgeon s role We (Cardiologist and Cardiac Surgeon) see and consent all patients We analyse their investigations particularly the CT-scan for annular sizing and access route. This is carried out at the work-station in the hybrid OR We adopted the policy of joint cardiologist and cardiac surgeon to attend all procedures The procedure requires two operators for valve deployment. We exchange skills as the boundaries between interventional structural cardiologist and cardiac surgeon are becoming interchangeable particularly at certain steps of the procedure

17 The Surgeon s role Provide open access for femoral artery whenever we considered the percutaneous route is not suitable Provide access for subclavian approach Surgical approaches including trans-aortic and trans-apical approaches Provide circulatory support including ECMO and cardiopulmonary bypass To deal with catastrophic complications: aortic complications ventricular complications vascular complications (interventional radiologists, vascular surgeon)

18 The Surgeon s role Integral part of the TAVI MDT Team Key decision maker Expanding the therapeutic options for patients Acquiring cath lab skills and in exchange cardiologists will acquire basic surgical skills Hybrid use of percutaneous and open surgical techniques The surgeons role is not only when the procedure goes wrong, but an active member of the team to deploy their skills to render the procedure safer. The surgeon will be able to deal with any complication in the hybrid lab and offer the patient a safer outcome

19 The Father of Dr Anderson had TAVI

20 The Ultimate Winners Are Our Patients

21 THANK YOU