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
Trans Apical AVI Technique
Transapical Procedural Steps Using The Ascendra Delivery System
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
Vessels should not be too Tortuous Diffuse PVD
Aortic valve annulus measurements 18-24 mm
No large Ischemic Area By Coronary Angiogram
High Risk Patients Suitable candidates for THV Age > 70 years? > 80 +++ 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
Not Only Euro & STS score!!
Not Only Euro &STS score!!
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
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)
TAVI at PSCC April 2009 October 2010 (Total of 27 patients) 20 TA Ed Sabien 7 TF Ed Sabien
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)
PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Demographic Data Euroscore Min/Max 10 /49 Mean 23 Age (yrs) 55 /105 79.6 Gender (F/M) 10 / 14 EF PAP (s) 25 / 65 25 /80 50.3 49.7
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 6/27 25.9% 37.0% 14.8% 66.6% 7.5% 48.1% 22.2 %
PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Demographic Data Min/Max Mean AVA Cm2) 0.4 / 0.8 0.55 Peak Ao Gradient (mmhg) 40 /144 91.3 Mean Ao Gradient 23 /80 52.8 Ao Annulus Size (mm) 19 / 25 23.2 RCI (mm) 4.5 / 13 8.8 REI (mm) 6 /10.3 8.4 RFA (mm) 6.3/10.3 7.8 LCI (mm) 4.4 /13 9.1 LEI (mm) 7.1/11.1 8.7 LFA(mm) 6.4 / 9.7 7.6
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 /27 44.4% 15 /27 55.6% 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%
PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Postoperative Complications DATA Postop. Paravalvular Leak Grade: 0 1 2 3 4 Postop Peak AV Gradient Postoperative EF Postop PAP MIN/MAX 8-33 25 65% 25 80 mm Hg 48% 18.5% 7.5% 0 0 Mean 19.8 mmhg 48.8% 47.5 mmhg
Mitral Regurgitation associated with TAVI Grades of MR Preoperative MR Postoperative MR 0 1 2 3 4 17 35 31 4 13 26 57 17 0 0 cardioalex june 2010
PSCC TAVI Patient s Data Edwards Sapien Valve (N=27) Postoperative Complications Cardiac Tamponade Apical Tear 2/27 1/27 7.4 % 3.7 % Coronary artery occlusion/embolisation Postoperative Bleeding (Reopening) 1/27 3/27 3.7 % 11.1 %
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%
Caution!! Distance Between LM & AVA?? A B LM C A <B, C/2<B
Heavy, Bulky AV Calcification??
Porcelain Aorta
Intraoperative TEE
Introperative 3-D Echo
Postoperative CTA
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.
If we do not anticipate the future..the future will take us.