Cardiac Valve/Structural Therapies

Transcription

1 Property of Dr. Chad Rammohan Cardiac Valve/Structural Therapies Chad Rammohan, MD FACC Medical Director, El Camino Hospital Cardiac Catheterization Lab Director, Interventional and Structural Cardiology, Palo Alto Medical Foundation

2 Heart Disease Heart attack MI Angioplasty Stenting Bypass surgery Angina 2

3 2 two-chamber pumps in series Pulmonary and arterial circulation 3

4 Heart Valves Inlet (Mitral) and outlet (Aortic) check flow valves to the left ventricle 4

5 Mitral Valve Mitral valve is a two leaflet structure that prevents blood from going backwards into the lungs

6 Mitral Regurgitation Chronic disease, 250,000 cases diagnosed annually Cause of refractory cases of congestive heart failure, atrial fibrillation, pulmonary hypertension

7 MR Series Close-up Normal Degenerative MR Prolapse Degenerative MR Flail Functional MR

8 Aortic Stenosis Degenerative disease 1/8 people over 75 have aortic stenosis Cause of refractory cases of congestive heart failure, fainting, chest pain, death

9 1944 Dwight Harken. First successful cardiac surgery 1945 Charles Bailey. First valve surgery Closed mitral commisurotomy for mitral stenosis 1954 C. Walt Lillehei. Open cardiac surgery. Cross circulation 1955 Cardiopulmonary bypass with heart lung machine 9

10 Surgical Mitral Valve Repair/Replacement Sternotomy Cardiopulmonary bypass ICU stay 1-2 days Hospital stay 5-7 or more days Repair, bioprosthetic or mechanical prosthesis, annuloplasty ring Ability to perform intra-op atrial fibrillation ablation and left atrial appendage ligation Advances with minimally invasive techniques and robotics Long term experience

11 Surgical Aortic Valve Replacement Sternotomy Cardiopulmonary bypass Cardioplegia ICU stay 1-2 days Hospital stay 5-7 or more days Repair, bioprosthetic or mechanical prosthesis, Long term experience

12 Transcatheter Valve Therapies Mitral regurgitation Transcatheter mitral valve repair (Abbott MitraClip) Aortic Stenosis Transcatheter aortic valve implantation (TAVR) - Medtronic CoreValve - Edwards Sapien

13 Transcatheter mitral valve repair (MitraClip) No sternotomy, cardioplegia, cardiopulmonary bypass General anesthesia Intraprocedural transesophageal echocardiogram with skilled echocardiographer Venous femoral access with transseptal puncture Hospital stay 1 day

14 Case: MitraClip 92 y/o with severe degenerative MR Severe posterior leaflet prolapse Severe regurgitation Severe pulmonary hypertension Congestive heart failure Paroxysmal atrial fibrillation Single vessel CAD Referred from cardiac surgery

15

16 Procedural course First case at El Camino Hospital 6/9/09 Referred by cardiac surgery No complications 2 Clips placed Discharged on hospital day #2 8 year follow up asymptomatic. Died at 101 of noncardiac causes

17

18 Aortic Stenosis Degenerative disease 1/8 people over 75 have aortic stenosis Cause of refractory cases of congestive heart failure, fainting, chest pain, death

19 Transcatheter Aortic Valve Replacement General anesthesia or sedation Femoral percutaneous arterial access with retrograde crossing of aortic valve Stent implantation Hospital stay 2-3 days Randomized trials shown equivalent or superior to surgical AVR in extreme, high, and intermediate risk patients

20 Trancatheter Aortic Valve Replacement (TAVR) 88 year old women with critical aortic stenosis O2 dependent emphysema History of lung cancer s/p lobectomy History of breast cancer s/p resection and radiation Recurrent admissions for heart failure

21

22

23

24 Immediate response Blood pressure normalized LV pressure normalized Cardiac output improved First week Needed pacemaker No oxygen requirement Ambulating without assistance Now 7 years later (Now 96) Home No further heart failure Independent

25 Multidisciplinary Heart Valve Team The management of patients with complex severe VHD is best achieved by a Heart Valve Team composed primarily of Cardiologists Surgeons Structural valve interventionalists Cardiovascular imaging specialists Cardiovascular surgeons Anesthesiologists Nurses Old Paradigm Interventionalist Patient Cardiologist Surgeon Emerging Paradigm Interventionalist Patient Cardiologist Surgeon Nishmura RA, et al. Circulation. 2014;129.

26 Heart Valve Centers of Excellence According to the AHA/ACC Guidelines: AHA/ACC 2014 Guidelines "The optimal care of the patient with complex heart disease is best performed in centers that can provide all available options for diagnosis and management, including the expertise for complex aortic or mitral valve repair, aortic surgery, and transcatheter therapies. This has led to the development of Heart Valve Centers of Excellence." Heart Valve Centers of Excellence 1) Are composed of experienced healthcare providers with expertise from multiple disciplines 2) Offer all available options for diagnosis and management, including complex valve repair, aortic surgery, and transcatheter therapies 3) Participate in regional or national outcome registries 4) Demonstrate adherence to national guidelines 5) Participate in continued evaluation and quality improvement processes to enhance patient outcomes 6) Publicly report their available mortality and success rates. Decisions about intervention at the Heart Valve Centers of Excellence should be dependent on the centers publicly available mortality rates and operative outcomes. It is recognized that some Heart Valve Centers of Excellence may have expertise in select valve problems Nishimura RA, et al. Circulation. 2014;129.