Emergency TAVI: Does It Exist? Is the Risk Higher?

Transcription

1 Emergency TAVI: Does It Exist? Is the Risk Higher? Gerald Yong MBBS (Hons) FRACP FSCAI Interventional Cardiologist Royal Perth Hospital Western Australia APCASH 12 October 2014

2 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 Grant/ Research Support: Consulting Fees/Honoraria: Company Edwards Lifesciences (consultant & proctor) Major Stock Shareholder/Equity Interest: Royalty Income: Ownership/Founder: Salary: Intellectual Property Rights: Other Financial Benefit:

3 89yo woman referred for TAVR NYHA 3 symptoms TTE Severe AS Vmax 4.7m/sec, mean gradient 55mmHg SAM with LVOT gradient 31mmHg Normal LV; Mild MR Co-morbidities GERD; Anaemia; Hypertension

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5 Management plan For cardiac catheter and balloon aortic valvuloplasty To assess what happens to LVOT gradient and SAM post-bav TTE annulus 21mm

6 Procedure scheduled for a Friday during school holidays.

7 Mean gradient 39mmHg

8 Aortogram Significant valve CA seen

9 BAV 22mm Nucleus

10 Immediate blood pressure!!

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14 Immediate resuscitation Pace at 100bpm

15 Urgent Heart Team meeting consisting of me running to OT to ask surgeon to operate on the patient Surgeon Too high risk, and I have a patient already with chest open. Why don t you fix it? For Emergency TAVI

16 And now to sort out the logistics

17 Perth 4.5 hours Headquaters of TAVI valve & clinical specialists

18 Fortunately. Edwards Lifesciences keep stock of SAPIEN valves and transfemoral kits in Perth (to save cost of transporting valves for regular TAVI cases)

19 Stock arrived (within 20 minutes)..

20 ARGHHH.

21 HOWEVER, fortunately again We have trained up three cathlab staff to prep transcatheter aortic valve. BUT.. Only the newest trained member was working that day!! OK that will do (Edwards clinical specialist from Sydney approved )

22 And the procedure moves on General anesthesia Transoesophageal echo guidance Transfemoral access 12Fr BAV sheath changed to Edwards E-sheath Annulus sized on TEE 20mm (!!) To use 23mm SAPIEN XT valve

23 Valve Crimping / Preparation (Fortunately there is also a manual)

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27 Phew

28 Progress Moderate LV impairment initially Improved within 7 days Progressive hyperdynamic LV with LVOT gradient Rx Recurrent pulmonary oedema High dose beta-blockes and calcium channel blocker PPM Currently NYHA 1-2 Sx Normal LV; No LVOT gradient.

29 Emergency aortic valve replacement Logistic EuroScore carried out before the beginning of the next working day STS Patients requiring emergency operations will have ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise, with or without hemodynamic instability, and not responsive to any form of therapy except cardiac surgery. An emergency operation is one in which there should be no delay in providing operative intervention.

30 LE 5.8% LE 23.8%

31 Other options Emergency BAV Emergency TAVR

32 Royal Perth Hospital Experience Emergency Aortic Valve Intervention Definition patient with recalcitrant heart failure / shock requiring inotrope, mechanical support or ventilatory support 17 Emergency BAV 4 Emergency TAVI

33 80yo man. Severe AS (mean gradient 60mmHg), mod AR, mod LV dysfunction. Awaiting SAVR. Rapid deterioration - cardiogenic shock, severe LV dysfunction, renal failure, liver failure inotropic support. BAV with residual mod-severe AR. Persistent pulmonary edema. CoreValve implanted. Moderate PVL LV improved. Currently still alive 88yo man Stenotic Mosaic valve with mod LV dysfunction VIV SAPIEN 6wks later early transcatheter valve stenosis cardiogenic shock, severe LV dysfunction IABP CoreValve implanted. Trace PVL LV improved. Currently still alive

34 85yo man Severe aortic stenosis (mean gradient 42mmHg); Normal LV function Awaiting TAVR Rapid decompensation with heart failure and shock inotropic support SAPIEN XT valve implanted. Mild paravalvular regurgitation Currently still alive 89yo woman Severe aortic stenosis (mean gradient 55mmHg); Normal LV; LVOT dynamic obstruction BAV acute severe AR moderate LV dysfunction SAPIEN XT valve implanted. Mild paravalvular regurgitation Currently still alive

35 Baseline Emergency TAVI (N=4) Age Logistic EuroScore 54.9% 32.7% Emergency BAV (N=17) Female 1 (25%) 6 (35.3%) Prev cardiac surgery 2 (50%) 1 (5.9%) Creat >200 1 (25%) 2 (11.8%) LVEF <30% 2 (50%) 8 (47.1%)

36 Pre-procedure mean gradient (catheter) Post-procedure mean gradient (catheter) Post-procedure moderate or severe AR Emergency TAVI (N=4) 20.3mmHg 4mmHg Emergency BAV (N=17) 38.3mmHg 20.6mmHg 1 (25%) 6 (33.3%)

37 Outcomes Emergency TAVI (N=4) Emergency BAV (N=17) In-hospital mortality 0 7 (41.2%) 30-day mortality 0 7 (41.2%) Stroke 0 0 Life threatening bleeding 1 (25%) 2 (11.7%) Major vascular complications 0 0 Acute kidney injury 2 or (11.7%) Subsequent SAVR N/A 2 (11.7%) Subsequent TAVR N/A 3 (17.6%)

38 Conclusions and Final Thoughts In acutely decompensated severe aortic stenosis, emergency TAVR is feasible Robust procedure which can be performed quickly with experience Offers much better hemodynamic outcomes compared to BAV

39 Conclusions and Final Thoughts Require readily available stock of transcatheter valve and personnel who knows how to prep. Another consideration - $$$ and cost utility In future with further improvement in valve technology and when above limitations are overcome, probably the first line for acutely decompensated severe AS will be emergency TAVR You won t think of offering emergency PTCA only for acute STEMI

40 56yo AVA 0.6cm 2, LVEF 16% Cardiogenic shock Pulmonary edema PVD incl subacute R leg ischemia Chronic pancreatitis Lung CA 1999 Cribier; Circulation 2002; 106(24):3006-8