Preprocedural evaluation for TAVR

Transcription

1 KEBE 30/05/15 Preprocedural evaluation for TAVR Ioannis Iakovou, MD, PhD Interventional Cardiology Onassis Cardiac Surgery Center Athens, Greece

2 Clinical Pathway: Developing Peri- Procedural Protocols KEBE 30/05/15 Communication Peri-procedural team Consensus agreements Equipment Procedural requirements (perfusion back-up, availability of blood products, management of complications) Quality assurance Case review Procedural practice review

3 KEBE 30/05/15 Pre-procedural checklist 1. Confirmation of aortic stenosis severity 2. Procedural feasibility: Aortic valve and aortic root anatomy and dimensions Peripheral artery anatomy 3. Exclusion of contraindications 4. Procedural approach selection Transfemoral Transsubclavian Transapical Direct aortic

4 KEBE 30/05/15 Pre-procedural evaluation for TAVR Echocardiography: Severity of AS Diameter of aortic annulus, ascending aorta, sinus of valsalva, distance of the aortic valve leaflets to sinotubular junction Presence of concomitant other valvular disease LVEF Left and right heart cath to evaluate concomitant CAD or PHT that may require treatment prior to valve implantation

5 KEBE 30/05/15 Pre-procedural evaluation for TAVR CT angiography of the aortic root to determine the optimal image orientation for valve positioninng and Diameter of aortic annulus, ascending aorta, sinus of valsalva, distance of the aortic valve leaflets to sinotubular junction CT angiography of the thoracobdominal and iliofemoral arteries to evaluate the diameter, tortuosity of the vessels, and classification to plan the access site.

6 TAVR and Access Routes Transfemoral Subclavian Direct Aortic Transapical

7 KEBE 30/05/15 Access site: Vascular or not? Femoral arteries: Diameter Tortuosity Stenosis Calcifications

8 KEBE 30/05/15 Access site: Vascular or not? tortuosity? calcium? porcelain aorta? not too dilated?

9 Aorta and Femoral-iliac vessels KEBE 30/05/15

10 KEBE 30/05/15 Ascending aorta diameter 43 mm for self-expandable device

11 Subclavian access KEBE 30/05/15 not much tortuosity not much calcifications when femoral arteries are small, so are the subclavian arteries LIMA

12 Direct aortic access KEBE 30/05/15 Ramlawi et al. J Thoracic Cardiovasc Surg 2014

13 Transaortic access: distribution of calcifications in the ascending aorta KEBE 30/05/15

14 Access site: Transapical? Imaging to assess: KEBE 30/05/15 LV apical aneurysm LV apical thrombus

15 Proposed access site algorithm Ramlawi et al. J Thoracic Cardiovasc Surg 2014 KEBE 30/05/15

16 Timing of the pre-procedural screening case example KEBE 30/05/15

17 Timing of the pre-procedural screening case example KEBE 30/05/15

18 KEBE 30/05/15 Timing of the pre-procedural screening case example RVD< mm

19 KEBE 30/05/15 Timing of the pre-procedural screening case example Transapical approach Engager

20 Preprocedural evaluation for TAVR cont d KEBE 30/05/15 Laboratory Tests Medications Peri-Operative Planning

21 KEBE 30/05/15 Preprocedural evaluation for TAVR Pre-Procedure Orders On Admission Laboratory Tests CBC CRP Type and Cross 4 units PRBCs Platelets PT, PTT, INR Electrolytes Urea, Creatinine Enzymes (CK, CK-MB, Troponin) BNP, NT-proBNP Chest X-ray ECG

22 KEBE 30/05/15 Pre-Procedure Orders On Admission Medications Discontinue warfarin (target INR < 2) Daily aspirin (81 to 325 mg/day) and daily clopidogrel (75mg/day) (or ticlopidine, if clopidogrel is contraindicated) for three days prior to the procedure 300 mg loading dose of clopidogrel on the day of the procedure Prophylactic antibiotic coverage on the day of the procedure as per hospital protocol Consider physiotherapy consultation for post procedure follow-up Reserve post procedure recovery bed (intermediate or intensive care) Consider renal protection for patients with renal insufficiency

23 Team Planning Day Before Procedure KEBE 30/05/15 Review screening evaluation (IC, CS, cardiac anesthesiologist) Review Risk Assessment and determine strategy accordingly Confirm vascular access and procedural plan Aortic valve size and anatomy (angulation, calcification, etc.) Access site, choice of sheath (hemostasis, potential need for retrieval), closure, tortuosity, treatment of potential perforation) Confirm availability of additional equipment (snares, covered stents, closure balloons, etc.) Talk to patient and family Confirm Informed Consent signed

24 Catheterization / Hybrid Lab Setup Everybody should be happy and comfortable KEBE 30/05/15

25 Evaluation Pathway KEBE 30/05/15 Hawkey et al, Transcatheter Aortic Valve Replacement Program Development: Recommendations for Best Practice, Catheter Cardiovasc Interv, 2014

26 KEBE 30/05/15 Conclusions Optimal pre-procedural planning and appropriate patient preparation will lead to safe and effective TAVR procedure. It is important to familiarize ourselves in best imaging practices to better select the appropriate strategy and to avoid complications.

27 Proposed Surgical Risk Assessment Guyton et al. TCT 2014 KEBE 30/05/15

28 KEBE 30/05/15 Examples of major organ system compromise ocardiac severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension ockdstage 3 or worse, opulmonary dysfunction with FEV1<50% or DLCO2<50% of predicted, ocns dysfunction (dementia, Alzheimer s Disease, Parkinson s Disease, CVA with persistent physical limitation), ogi dysfunction Crohn sdisease, Ulcerative Colitis, nutritional impairment or serum albumin < 3.0, ocancer-active malignancy, oliver any history of cirrhosis or varicealbleeding

29 KEBE 30/05/15 Surgical Impediments -Examples Tracheostomy present Heavily calcified ascending aorta Chest malformation or radiation damage Extreme obesity (pannus1/3 the way down thighs)

30 A Practical Guide to Multimodality Imaging of Transcatheter Aortic Valve Replacement J Am Coll Cardiol Img. 2012;5(4): doi: /j.jcmg Transesophageal Echocardiography Biplane Imaging to Assess Annular Dimensions and Predict Aortic Regurgitation (A) Biplane imaging during balloon inflation. The green arrows identify the waist of the balloon at the level of the annulus. The blue arrow shows asymmetric balloon dilation at the commissure between the left and noncoronary cusps. The yellow arrows depict acoustic shadowing, which prevents adequate visualization of the peri-balloon region (see Online Video 2 for a moving image of using balloon aortic valvuloplasty for sizing). Biplane Date of download: Copyright 3 rd imaging immediately after transcatheter aortic valve replacement of the case from (A) shows aortic regurgitation at the sites predicted THV The American during Meeting balloon College Hygeia aortic of Cardiology. valvuloplasty 2014 (red arrows) (B). See Online Video 2. 2/26/2015 All rights reserved.

31 From: A Practical Guide to Multimodality Imaging of Transcatheter Aortic Valve Replacement J Am Coll Cardiol Img. 2012;5(4): doi: /j.jcmg Figure Legend: Aortic Root Anatomy (A) Diagram of aortic root anatomy showing coronet shape and location of various annular planes and coronary ostia relative to leaflet attachments. (B) Imaging planes and leaflet attachments from (A) shown superimposed on postmortem specimen. A-M = aorto-mitral; VA = ventriculo-arterial. Date of download: 2/26/ rd THV Meeting Hygeia 2014 Copyright The American College of Cardiology. All rights reserved.

32 TAVR Indications Patient selection in clinical trials Logistic EuroSCORE >20% or STS Score > 10. J. Am. Coll. Cardiol. 2012;59;

33 TAVR Indications J. Am. Coll. Cardiol. 2012;59;

34 KEBE 30/05/15 TAVR Indications Nishimura Circ/JACC 2014