Presentación de PowerPoint - SOLACI · Total number of valves implanted by size, 2011-2014 Angiografía de Occidente S.A. Cali- Colombia. 2016 Center experience: Angiografía de

Genero: Masculino Edad: 80 años Peso: 73 kg Estatura: 1.70 mts BMI: 25.2

Antecedentes:1. DM, HTA, ERC, EPOC, FA.2. INSUFICIENCIA VALVULAR AORTICA SEVERA.3. ICC CON FEVI 45%

Clínica: NYHA III/IV E ICC DESCOMPENSADA

CASO N°1:

STS Score:Mortalidad: 7.27%Morbimortalidad: 28.81%

Coronariografía:

Ventriculograma + Aortograma:

Ecocardiograma:

Ecocardiograma:

MECANISMOS Y ETIOLOGIAS DE LA INSUFICIENCIA

AORTICA

Cúspides anómalas o

perforadas

Endocarditis

Enfermedad Reumática reumatoide

Espondilitis Anquilosante

Dilatación de la raíz

Aortica con mala

coaptación de las

cúspides

Espondilitis Anquilosante

Enfermedad Reumatoide

Sífilis

Ehlers-Danlos

Pseudoxantomas elásticos

Falta de soporte en las

comisuras con

deficiente coaptación

de las cúspides

aorticas

Tetralogía de Fallot

Defecto del septo Ventricular

Disección de Aorta

Aortitis

Trauma

Etiology of Aortic Regurgitation

SEVERE AI SECONDARY TO LVADIMPLANTS INCREASING

EXPONENTIALLY.

MSCT:

MSCT: PERIMETRO 87 mm

Acceso Vascular Derecho:

Acceso Vascular Izquierdo:

JenaValve

SymetisValve

COREVALVE:

Total number of valves implanted by size, 2011-2014 Angiografía de Occidente S.A. Cali- Colombia. 2016

Center experience: Angiografía de Occidente S.A. registry, Cali-Colombia 2011-2014

(33%)

(15.5%)

(7.5%)

NO PPM

PPM: 120 LPM PPM: 140 LPM

RECAPTURA DE LA VALVULA

MCP 160 LPM

NUNCA LIBERAR SIN MARCAPASOS

PPM OFF

Outcomes According to Devices

Mortality and Post-

Procedural Aortic Regurgitation

Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017

All cause mortality predictors

STS Score

LVEF < 45%Mitral Regurgitation > Moderate at baseline

POST-PROCEDURAL AORTIC REGURGITATION > MODERATE

Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017

Predictors of ComplicationsEarly Vs Late Experience

Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017

• 72 años

• Mujer

Antecedentes:

• Artritis reumatoide severa

• FEVI: 30%

• 6 meses evolución falla cardiaca con progreso a estadio IV

• Endocarditis Marantica

CASO N°2:

MSCT: PERIMETRO 79mm

Evolut R 29

PPM: 120 LPM PPM: 140 LPM

PPM: 140 LPM PPM: OFF

NUNCA SUSPENDER ARREO CON MARCAPASOS EN EL MOMENTO DE LA LIBERACION DEFINITIVA

• 78 y.o STS: 8,5• Heart Failure• Degenerative Cerebral Disease (Mild to moderate)• Hypertension • Chronic Alcoholism• Echocardiogram:

• Severe Aortic Insufficiency IV/IV• EF: 35%

• Creatinine: 2.0

CASO N°3:

Aortic Regurgitation

18 19 20 21 22 23 24 25 26 27 28 29 30

56.5 62.8 72.3 81.7 94.2

23 mm 26 mm 29 mm 34 mm

Diameter (mm)

Perimeter (mm) †

Evolut R System

PERIMETRO: 95mm

Aortic Regurgitation

Angulo: 61°

No PPM PPM 130

PPM 150

Critical moment to release the device

Second Attempt

Third AttemptOscillatory Movements of the DeviceAumento de PPM a 170 lpm

Mantaining PPMEven after last 1/3 of reléase PPM

170

Final Result

Challenges in treatment of non-calcified AR

Insufficient anchoring

Dislocation / embolisation

Residual AR

Annular rupture

Concomitant aortic dilation

Large annuli

PHASES FOR DEVICE RELEASE

First Phase: Absence of Displacement, Peacemaker not needed (stable system).

No PPM PPM 130

First Phase: Should start peacemaker at 130 to 150 bpm.

BPM 150

Critical moment to release the

device

Second phase: Even with PPM 150 BPM the system hasn’t achieved annular contact with the annular system,

you can tell by the movement. Displacement should be avoided and Increase pacing at 170-180 BPM.

Third Phase: SPIN OFF Movement. At no-Recapture point the valve is still out of adequate

contact, and is still bound to migrate unless we increase the pulse rate. (BPM 160-180)

Fourth phase: No movement, achieved at rates between 180 - 200 BPM.

M, 75YO.

W: 75KG, H 172CMS, STS: 6,2% RISK.

5 months of functional class deterioration NYHA III.

ECHO:

• LVEF 53%, AV: SEVERE INSUFFICIENCY, CV:7mm. SPP:50mmHg.

• MV: Moderate Insufficiency.

CORONARY ARTERIOGRAPHY

• No coronary artery disease

• LVEF 50%

• AV: Severe Regurgitation IV/IV

CT:

• LVEF 49%, Diameter Min: 23,6mm Max. 28,7mm. Perimeter 86,5mm

CASO N°4:

ECHO

DIAGNOSTIC ANGIOGRAPHY

CORONARY

CT

Multiple Options for Vascular Access

Direct aortic

Subclavian/Axillary

Transapical

Transfemoral

Carotid

Common IliacRPA

IVC to Aorta Entry

Transeptal Supranavicular

Access Selection

Femoral Access

Left Axillary Access

Direct Aortic Access

Supra Aortic Arch Access

Trans-apical Access

PercutaneousLocal anesthesia

Surgical cut-downGeneral anesthesia

Surgical cut-downGeneral anesthesiaThoracotomy

Surgical cut-downGeneral anesthesiaThoracotomyVentriculotomy

Caval-Aortic Access

Trans Venous/Septal

- Femoral Vein

- Yugular Vein

Supranavicular Access

Carotid Access

Strategy

Subclavian access

Illiac Access

Subclavian Technique1.Surgical cut down

2.Place two (2) vessel loops around axillary artery

3.Place two (2) standard double purse-string sutures* and create an oval-shaped axillary artery access incision starting at downstream edge of purse-string sutures.

4.Use direct cannulation

Subclavian Technique

5.Advance 18 Fr introducer over super stiff guidewire

6.Position distal end of 18 Fr introducer immediately distal (upstream) to innominate/brachiocephalic artery

7.Full valve functionality and partial repositionability provide time for evaluation and adjustment.

8.Withdraw delivery catheter, remove introducer, and utilize purse-string sutures to maintain effective hemostasis.

Angle: 86°

AREA: 44 mm

Perimeter: 83,5mmArea: 54,5mm

DIAMETER: 15,4 cms2,89 cms

PROCEDURE

WIRE IN HORIZONTAL PLANE, NOT BELLY UP.

PULL BACK

LIBERACION CON PPM A 120

Gender: Male

Age: 64 y.o.

Weight: 68 kg

Height: 1.70 mts

Medical History:Severe Aortic Regurgitation

Coronary Artery Disease (Stent DA 2013)

HT

COPD

Peripheral Vascular Disease Aortic dissection type B

CHF

CKD (Creat: 1.65)

Symptoms: NYHA III/IV

STS Score:

Mortality: 9.42%

Euroscore: 10.48%

CASO N°5:

Gender: Male

Age: 72 y.o.

Weight: 74 kg

Height: 1.68 mts

Medical History: Severe Aortic Regurgitation

LV disfunction

HT

COPD

DM2

PPM 2016

CASO N°6:

Coronary Angiography, Ventriculogram and Aortogram

Valve Deformation During Snare