Διαδερμική θεραπεία των παραβαλβιδικών διαφυγών Σ.Ράμμος

Transcription

1 ΔΜΙΝΑΡΙΟ ΔΠΙΣΗΜΟΝΙΚΩΝ ΔΝΩΔΩΝ ΔΛΛΗΝΙΚΟΤ ΚΟΛΛΔΓΙΟΤ ΚΑΡ ΙΟΛΟΓΙΑ Δπιζηημονική Ένωζη Δπεμβαηικής Καρδιολογίας Βαλβιδοπάθειες, Γιαδερμικές παρεμβάζεις Διαδερμική θεραπεία των παραβαλβιδικών διαφυγών Σ.Ράμμος

2 Incidence and Clinical Impact of Paravalvular Leak Postop aortic PVL ~ 5% after TAVR ~7.4% (moderate or severe,jacc 2012) Postop mitral leaks ~12% Symptoms often less severe in Αο. than in mitral PVL Data from 3201 SAVR pt., mean follow up 4.5±3.4 y Survival (y) AR>1+ AR< PARTNER study suggested that any PVL regurgitation (mild moderate severe) was associated with increased mortality at 2 years

3 Echocardiographic Criteria for Grading PVL Parameter Mild Moderate Severe Structural parameters Left ventricular size Normal Normal/mildly dilated Dilated Jet width in central jets (% diameter): color Narrow ( 25%) Intermediate (26% to 64%) Large ( 65%) Jet density: CW Doppler Incomplete or faint Dense Dense Jet deceleration rate (PHT, ms): CW Doppler LV outflow vs. pulmonary flow: PW Doppler Diastolic flow reversal in the dao by pulsed wave Circumferential extent of PVR (%) Quantitative parameters Slow (>500) Variable ( ) Steep (<200) Slightly increased Intermediate Greatly increased Absent or brief early diastolic Intermediate Prominent, holodiastolic <10% 10% to 29% 30% Regurgitant volume (ml/beat) <30 ml ml 60 ml Regurgitant fraction (%) <30% 30% to 50% 50% EROA (cm 2 ) <0.10 cm cm cm 2

4 Possible intervention Success Risk percutaneous closure Procedural success for percutaneous closure of paravalvular leaks ca 90% Complication rates at 30 days ca 10% Mortality related to the procedure ca 1%

5 Literature overview on transcatheter closure of paravalvular leaks; technical success defined as successful device implantation. Lutz Buellesfeld, and Bernhard Meier MMCTS 2011;2011:mmcts European Association for Cardio-thoracic Surgery

6 Before the Procedure Clinical exam, TTE, 3-D, Chest X-ray Blood tests - Hemoglobin, LDH - Degree of hemolysis? - Leucocytes, CRP Endocarditis prophylaxis General anesthesia stand-by TEE always for mitral leaks stand-by for aortic leaks Heparin 5,000-10,000

7 Device should match the anatomy!

8 Devices Amplatzer VSD Occluder PDA Occluder

9 Amplatzer Vascular Plug (AVP-I) Diameter: 4-16 mm Length: 7-8 mm AVP-II Diameter: 3-22 mm Length: 6-18 mm Compatible sheath: 5-8 Fr Occludes twice faster than AVP (I)

10 Amplatzer Vascular Plug III Oval-shaped Thinner wires More wires Multiple layers smaller pore size improved surface contact faster occlusion Amplatzer Vascular Plug IV

11 How to Close? Cross the leak with -5F diagnostic cath " hydrophilic wire Long sheath -6-8 F -Hydrophilic Orthogonal view of the valve Check the motion of the valve leaflets Device implantation Check valve leaflet motion again before device release

12 3 ways to cross: Right or left Judkins, Terumo wire, TEE guidance!!, Steerable sheaths (Agilis, St. Jude Medical) 4 ways to introduce the sheath and the device 1)Retrograde via the aorta 2) From SVC Transeptal LA 3) From IVC Transeptal LA 4)Transapical Arteriovenous Loop?

13 AV-loop. Lutz Buellesfeld, and Bernhard Meier MMCTS 2011;2011:mmcts European Association for Cardio-thoracic Surgery

14 A, Parasternal longitudinal axis tranesesophageal echocardiography (TEE) view showing moderate paravalvular leak post transcatheter heart valve deployment. Stamatios Lerakis et al. Circulation. 2013;127: Copyright American Heart Association, Inc. All rights reserved.

15 Transcatheter closure after aortic valve replacement. Lutz Buellesfeld, and Bernhard Meier MMCTS2011;2011:mmcts

16 DA/73593: large PVL, NYHA III-IV, PPA>80 mmhg CATH 30/06/15: Amplatz / 6/6 PDA / 14/6 PDA / 18mm VSD postimplantation massive Haemolysis Post PPA<50 mmhg, NYHA II

17 Summary and Future Directions Incidence of aortic PVL ~ 5% after TAVR ~7.4% (moderate or severe ) Postop mitral leaks ~12% Symptoms often less severe in aortic than in mitral PVL Use always the Echocardiographic criteria for grading PVL The Device should match the anatomy! Procedural success for percutaneous closure ~90% As the use of TAVR expands to lower risk groups, the need to treat PVL with new techniques is essential to ensure a favorable risk benefit ratio for the patient.