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Trans-catheter Aortic Valve Implantation Should we all be doing this?

Trans-catheter Aortic Valve Implantation Should we all be doing this?. Dr Philip MacCarthy BSc PhD FRCP Consultant Cardiologist King’s College Hospital, London, UK. BCIS Autumn Meeting, Crewe Hall, Crewe, September 26th 2008. Otto et al N Engl J Med 1999;341:142–7 . Is there an unmet need?.

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Trans-catheter Aortic Valve Implantation Should we all be doing this?

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  1. Trans-catheter Aortic Valve ImplantationShould we all be doing this? Dr Philip MacCarthy BSc PhD FRCP Consultant Cardiologist King’s College Hospital, London, UK. BCIS Autumn Meeting, Crewe Hall, Crewe, September 26th 2008

  2. Otto et al N Engl J Med 1999;341:142–7

  3. Is there an unmet need?

  4. AVR has become more common in the elderly (SCTS 5th Blue Book 2003)

  5. Is there an unmet need?

  6. What do we currently have to offer?

  7. Trans-catheter aortic valve implantation • CoreValve ‘Revalving’ system – trans-femoral • Edwards Sapien™ prosthesis • Trans-femoral (using the ‘RetroFlex’ catheter) • Trans-apical (using the ‘Ascendra’ catheter)

  8. CoreValve ‘ ReValving’ System

  9. Edwards Sapien™ Trancatheter Heart Valve prosthesis

  10. What are the challenges of setting up a TAVI programme in the real world?

  11. King’s College Hospital Experience • 35 patients treated with the Edwards device • 17 Trans-femoral • 18 Trans-apical • First 17 of these as part of the PARTNER-EU study, • Next 18 in the SOURCE registry

  12. King’s College Hospital Experience • 20 women (57%) • Mean age - 83.9yrs • Mean Log Euroscore - 20.3 (porcelain aorta) • Mean peak AV gradient - 85.8mmHg • Mean AVA - 0.61cm2 • Median LOS - 8 days • In-hospital mortality - 2 (5.7%)

  13. Patient work-up • Lung/renal function tests • Carotid Dopplers • CT aorta – without contrast • Trans-thoracic echo • Morphology of AV – peak/mean grad + AVA • Dimensions of AV annulus • Morphology of septum • Presence/mechanism of MR • LV systolic function • PAP if possible • TOE – if annulus 24mm or greater

  14. Patient work-up • Cardiac Catheterisation • Coronary angiogram • RH cath with PAP • Aortogram (PA or LAO) – 30ml @ 15ml/sec • Iliofemoral angiogram – 30ml @ 6ml/sec • No angioseal!

  15. The Team • Dedicated Anaesthetist(s) • Echocardiologist • Perfusionist • Surgical scrub nurse • Cath lab scrub nurse • Surgeon(s) • Interventional Cardiologist(s) • The Company (for valve crimping)

  16. CP bypass Surgicalkit Screens Echo Machine Nurse CT Surg Echo Fluoro Rad Nurse Cardio Tech Anaes. Machine Anaes Cath lab kit ODA Valve crimping Rep

  17. The Learning Curve

  18. Trans-femoral pAVR

  19. TF Valve deployment

  20. Trans-apical pAVRA higher risk patient group

  21. TA valve deployment

  22. The importance of peri-procedural imaging

  23. Stenosed native aortic valve

  24. Guidewire across native AV

  25. Valve deployment

  26. Edwards Sapien valve in-situ

  27. Potential peri-procedural complications • Vascular access • Passage of introducer sheath • Surgical repair • Iliac dissection/rupture • Balloon valvuloplasty • Aortic regurgitation • CHB on background of RBBB • Valve deployment • Occlusion of coronary ostia • Displacement of prosthesis • Rapid pacing • Other – • Interference with the mitral valve • CVA

  28. Failed femoral access

  29. Iliac balloon occlusion

  30. Occlusive iliac dissection

  31. Iliac artery rupture…

  32. …repaired with a covered stent

  33. The importance of case selection • Patients with advanced pulmonary disease may do better with a TF approach • Poor LV systolic function - less room for error • The aetiology of depressed LV function and MR • Beware RBBB

  34. So should we all be doing it?

  35. Some words of caution • The precise need is unknown • There is currently no long-term data • Funding issues remain a problem

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