Challenging Case. 89 year old man 5/11/2016. Prior 31 mm CoreValve NYHA III Moderately-severe PVL

Transcription

1 5/11/2016 Vumedi May year old man Challenging Case Prior 31 mm CoreValve NYHA III Moderately-severe PVL Paul Sorajja, MD Director, Center for Valve and Structural Heart Disease Minneapolis Heart Institute Abbott Northwestern Hospital Disclosures: off-label use of AVP s 1

2 5/11/ cm Whisper coronary wire No glidewire will pass What now? What delivery catheter? 2

3 5/11/2016 Quickcross catheter Rewiring, quickcross, glidewire 15 mm Gooseneck 3

4 5/11/2016 4

5 Valve in valve with high risk of coronary occlusion Itsik Ben-Dor MD, Augusto Pichard MD. Medstar Washington Hospital Center. Washington, DC Case ViV Relevant history 89 year-old woman with multiple co-morbidities and frailty presents with progressive SOB and chest discomfort s/p AVR + CABG 2004 (21mm Synergy LIMA to LAD, SVG to RCA) PMH: s/p Lt. CEA HTN HLP Bioprosthetic valve Model: Mitroflow Synergy 21 mm Labeled ED: 20.7 Labeled ID: 17.3 True ID: 17 STS score: 9.66 Fail frailty 1500 pts 1

6 % patients 5/12/2016 Incidence of Coronary Obstruction in Large Studies 3 2 Incidence is usually less than 1% CoreValve Sapien Both Advance 1 France 2 German 3 Canadian 4 SOURCE 5 PARTNER 6 SOURCE XT 7 Overall 8 Metanalysis 9 Ribeiro HB et al. JACC Interv Linke a et al, ACC Eltchaninoff et al, Eur Heart J Zahn et al, Am J Cardiol Rodes-Cabau et al, JACC Thomas et al, Circulation Smith et al, NEJM Wendler et al, EuroPCR Ribeiro et al, Jacc Interv Khatri et al, Ann Intern Med 2013 Incidence of Coronary Obstruction According to Valve Type and Valve-in-Valve Procedure Ribeiro HB et al. JACC 2013 Incidence of Coronary Obstruction According to Valve Type and Valve-in-Valve Procedure Global Valve-in-Valve Registry Overall Stented Stentless MitroFlow (not (Not (stented) Mitroflow) Freedom) Dvir D. Circulation

7 Echo Echo Variable (TTE) Measure Valve Peak Velocity Mean Gradient Calculated AVA Calculated AVA index Severity of AR Severity of MR 21mm Synergy 3.8 m/s 33 mm Hg 0.5 cm2 0.4 cm2/m2 Mild Mild Ejection Fraction 60-65% TTE/TEE annulus diameter Is echo within window? If OOW, date will be repeated RV Pressures Dobutamine Resting EF Mcg used Peak Velocity Mean Gradient 1.9 cm Y N/A 39 mmhg N LMCA has low origin in the LC Sinus Patent LIMA-LAD Atretic SVG-PDA CT Analysis Short Annulus Diameter Long Annulus Diameter Annular Perimeter Annular Area 18.1 mm 18.4 mm 58.5 mm 271 mm2 3

8 CT Analysis Sinus of Valsalva Diameter Sinotubular Junction Diameter Left Coronary Height Right Coronary Height 27 x 27 x 28 mm 26 X 24 mm 7 mm 13.1 mm Long Mitroflow Leaflets shown by CT. They extend beyond the coronary ostia. CT Analysis 4

9 Procedure Conscious Sedation 5F pigtail through Right radial. Two 5F sheaths in right fem artery for LC and RC guiding catheters. BMWs with undeployed stent into mid CX and mid RCA. No BAV Standard 23mm Sapien XT deployment SAPIEN-XT: 23mm in 21mm mitral flow valve In view of CT findings, with long mitroflow leaflets going above the coronary ostia, and high risk of coronary occlusion, it was planned to deploy both stents even if flow into coronaries is adequate after valve implantation. We were aware that coronary occlusion can occur hours (or days?) after valve implantation. 5

10 SAPIEN-XT: 23mm in 21mm mitral flow valve Left- EBU 3.5 / Xience 3.5/18mm Right HS/ Xience 3/15mm SAPIEN-XT: 23mm in 21mm mitral flow valve SAPIEN-XT: 23mm in 21mm mitral flow valve 6

11 After Valve Deployment and stent delivery Aortogram before Stent Deployment Aortogram after Stent Deployment Mitroflow leaflet in front of LMCA Outcome Final Gradient: 12 mm Hg No AR Excellent outcom discharge home day 4 Summary Coronary obstruction following TAVI is a rare (0.66%) but life-threatening complication Low lying coronary ostia (specially a LCA height <12 mm), and a narrow aortic root (<30 mm) appeared as important risk factors on CT related to the occurrence of coronary obstruction Bioprosthetic valves with higher risk for coronary obstruction include stentless valves, valves with leaflets sutured outside of the stent and valves with supra-annular position 7

12 Summary If in doubt, protect coronary with a guidewire & stent (parked distal to ostium) If unable to cannulate coronary due to coronary obstruction, pull the valve with balloon or snare into ascending aorta In low coronary anatomy, consider using a repositionable valve to ensure proper function without causing obstruction 23 core valve in bio prosthetic valve 78 year-old woman with multiple co-morbidities including prior AS s/p AVR in 2006 with a Medtronic Freestyle Stentless 25mm Bio-prosthetic Valve LVOT: 1.9 cm V2: 2.3 m/sec Mean gradient: 12 mmhg Aortic valve area: 1.2 cm2 Dimensionless Index: 0.47 Moderate AS Moderate-to-severe AR EF : 40% 23 core valve in bio prosthetic valve EBU 3.5 4/16mm Promus 8

13 23 core valve in bio prosthetic valve 23 core valve in bio prosthetic valve 23 core valve in bio prosthetic valve 9

14 23 core valve in bio prosthetic valve 23 core valve in bio prosthetic valve Maxi 25mm / 4cm 10

15 5/17/2016 The Heart Valve Society presents I Can Do TransCaval TAVR Vasilis Babaliaros, MD Co Director, Emory Structural Heart and Valve Center 34 year old Female with Congenital Mitral Stenosis 2 Previous Sternotomies for tissue mitral valve and currently with mechanical mitral valve Progressive fatigue and decreased activity and mean subaortic membrane of 65 mm Hg Progressive cognitive dysfunction and poor surgical candidate Referred for catheter therapy First Problem: SubAortic Stenosis 1

16 5/17/2016 Second Problem: Access Needs Alternative Access No drains and Short ICU stay per family Proposed for Transcaval Approach 1. Abdominal Aorta 8mm 2. Distance >10 mm Basic Principles of TransCaval TAVR Greenbaum et al JACC 2014 TransCatheter Heart Valve Therapy for SubAortic Stenosis 2

17 5/17/2016 TransCatheter Heart Valve Therapy for SubAortic Stenosis Uncomplicated Crossing Distance dictates PDA closure device 14Fr EW esheath utilized TransCatheter Heart Valve Therapy for SubAortic Stenosis 20 mm Balloon with waist that resolves and seals with further inflation TransCatheter Heart Valve Therapy for SubAortic Stenosis Deployed deep in LVOT to cover narrowing and reach annulus 3

18 5/17/2016 TransCatheter Heart Valve Therapy for SubAortic Stenosis S3 completely sub-valvular with no PVL and 15mmHg mean gradient TransCatheter Heart Valve Therapy for SubAortic Stenosis PDA closure complicated by Ao-IVC fistula and 20mmHg aortic gradient TransCatheter Heart Valve Therapy for SubAortic Stenosis Soft 9mm balloon inflation resolves fistula and gradient (5mmHg) 4

19 5/17/2016 Evolution and Conclusions Patient was discharged POD#1 30 day follow-up showed continued resolution of subaortic stenosis Proof of concept for stenting of the LVOT with THV Feasibility of transcaval approach for next day discharge and small abdominal aortas 5

20 Complex Left Atrial Appendage Closure with the Watchman Device Brian Whisenant, MD Intermountain Heart Institute May 2016 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Consultant/Equity Payment Consultant/Honoraria Company Coherex Medical/JNJ Boston Scientific Patient History 79 year old woman 20 year history of AF Remote partial colon resection secondary to diverticulitis 3 major (~ 4U PRBC) GI bleeds: 2 Pradaxa, 1 warfarin. Diverticulosis CHA2DS2-VASc score of 5 HTN 1 Age 2 Female - 1 1

21 Baseline TEE Ostial Diameter Behind Limbus 2.6 Depth Suboptimal trajectory with < 15 mm wall to ostium Little opportunity for transseptal optimization: Posterior in fossa Low on BiCaval TEE Superior Trajectory = Anterior Trajectory Need Superior Trajectory Need Anterior Trajectory Anterior Superior Superior Lobe angles anteriorly Posterior lobe angles posteriorly Inferior Posterior 2

22 Switched to Anterior Curve Sheath Anterior Superior Wing Predicted from TEE PA PA Rotation Approximates Fluoro What Size Watchman? A. 21 mm B. 24 mm C. 27 mm D. 30 mm E. 33 mm Ostium: Neither round Nor Planar 3

23 27 mm Watchman Deployment Insufficient Depth & Width 27 mm Watchman Position Conclusion Insufficient compression Excessive oversizing & inadequate depth forced proximally Device retrieved 24 mm Watchman 4

24 24 mm Watchman Posterior Cavity What Did I Learn Coaxial delivery is always helpful if not essential. Excessive oversizing is sometimes not tolerated. Trust the tug test Understanding LAA anatomy and correlation with imaging translates to improved clinical outcomes S. Cottonwood Street Salt Lake City, UT intermountainheartinstitute.org 5