Prince Sultan Cardiac Center Experience Riyadh, Saudi Arabia

Transcription

1 Transcatheter Transapical Aortic Valve Implantation Prince Sultan Cardiac Center Experience Riyadh, Saudi Arabia Ahmed Elwatidy, MD,PhD, FRCS S Kassab, MD,S Ahmari, MD, H Amri, MD, H Ismail, MD, A Calafiori, MD Adult Cardiac Surgery & Adult Cardiology Departments 22 nd SHA Annual Conference, Riyadh, Feb 2011

2 Trans Apical AVI Technique

3 Transapical Procedural Steps Using The Ascendra Delivery System

4

5 PATIENT INDICATIONS AVA < 0.8 cm2 Symptomatic Aortic Stenosis STS > 10 Euroscore > 20 % Risk Evaluation 26 mm > 8 mm 23 mm > 7 mm Femoral Minimal Diameter

6 Vessels should not be too Tortuous Diffuse PVD

7 Aortic valve annulus measurements mm

8 No large Ischemic Area By Coronary Angiogram

9 High Risk Patients Suitable candidates for THV Age > 70 years? > Combination of several commorbidities (Renal, respiratory failure, LV dysfunction ) Contra indication to surgery (Porcelain Aorta, chest radiation, ) Not too frail or too much debilaty Not only the scores, (Fraility test!!) TA or TF technically feasible

10 Not Only Euro & STS score!!

11 Not Only Euro &STS score!!

12 Transapical Indication: Diffuse Peripheral Vessels Small vessel Diameter (less than 7.5 mm) Less than 6 mm For Novaflex system Porcelain Aorta Extensive tortuosity of vessels Failure of BAV Unable to cross native valve TF procedural complications

13 Summary of TAVI Cases at PSCC (April 2009 October 2010 ) (18 month) 31patients : Planned for the procedure 27 patients had already the procedure (27 Edwards Sapien valve)

14 TAVI at PSCC April 2009 October 2010 (Total of 27 patients) 20 TA Ed Sabien 7 TF Ed Sabien

15 Summary of TAVI Cases at PSCC Why some planned cases are not done?? 21 patients : Planned for Transapical 20 successful TA Ed Sapien Valve 1 patient postponed due to (apical tear) 10 patients: Planned for Transfemoral 7 successful TF Ed Sapien V procedures, 1 Patient cancelled (low Trans aortic Gradient) 1 TF TA due to (RV perforation, Tamponade) 1 patient TF Classic AVR (Bulky Calcification, LM potential Ostial obstruction)

16 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Demographic Data Euroscore Min/Max 10 /49 Mean 23 Age (yrs) 55 / Gender (F/M) 10 / 14 EF PAP (s) 25 / /

17 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) COPD Renal Impairment (Cr>200) CVA PVD Porcelain Aorta Mod CAD/ Previous PCI Previous CABG 7/27 10/27 4/27 18/27 2/27 13/27 6/ % 37.0% 14.8% 66.6% 7.5% 48.1% 22.2 %

18 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Demographic Data Min/Max Mean AVA Cm2) 0.4 / Peak Ao Gradient (mmhg) 40 / Mean Ao Gradient 23 / Ao Annulus Size (mm) 19 / RCI (mm) 4.5 / REI (mm) 6 / RFA (mm) 6.3/ LCI (mm) 4.4 / LEI (mm) 7.1/ LFA(mm) 6.4 /

19 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Demographic Data Min/Max Mean Size (26 mm) Sabien Valve Size (23 mm) Sabien Valve Hospital Stay (days) Over all Mortality (1 month) Over all Mortality (1 year) TA Mortality TF Mortality 12 / % 15 / % 2 -->30 2 /27 4/27 2/20 2/7 85.2% 1 year survival 12.5 Median 7 days 7.4% 14.8% 10% 28.5%

20 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Postoperative Complications DATA Postop. Paravalvular Leak Grade: Postop Peak AV Gradient Postoperative EF Postop PAP MIN/MAX % mm Hg 48% 18.5% 7.5% 0 0 Mean 19.8 mmhg 48.8% 47.5 mmhg

21 Mitral Regurgitation associated with TAVI Grades of MR Preoperative MR Postoperative MR cardioalex june 2010

22 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Postoperative Complications Cardiac Tamponade Apical Tear 2/27 1/ % 3.7 % Coronary artery occlusion/embolisation Postoperative Bleeding (Reopening) 1/27 3/ % 11.1 %

23 PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Postoperative Complications Postop PPM Postop CVA Postop Dialysis Vascular Complications Re-intubation Wound Infection 0/27 1 / 27 4/27 1/27 3/27 2/27 0 % 3.7 % 14.8 % 3.7 % 11.1% 7.4%

24 Caution!! Distance Between LM & AVA?? A B LM C A <B, C/2<B

25 Heavy, Bulky AV Calcification??

26 Porcelain Aorta

27 Intraoperative TEE

28 Introperative 3-D Echo

29 Postoperative CTA

30 Conclusion: Percutaneous Aortic Valve Implantation is a very feasible technique for difficult High- Risk surgical patients. It provides GOOD Hemodynamic and Clinical improvements Still, Should be tailored restricted to High Risk AS patients T A Technique will continue to have a good place for certain group of patients.

31 If we do not anticipate the future..the future will take us.