marie erpicum – perfusionniste département de chirurgie cardiovasculaire et thoracique - chu de...
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Transcatheter Aortic Valve Implantation
Marie Erpicum – Perfusionniste Département de chirurgie cardiovasculaire et thoracique - CHU de
Liège
Marie ErpicumPerfusionnist
Cardiovascular & Thoracic surgery departmentCHU of Liege
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Since 2002…
…to this day
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Homograft – 1960
Porcine valve – 1965
Pericardial tissue valve – 1969
CoreValve Transcatheter AVR by Retrograde ApproachLaborde, Lal, Grube – 2004
Edwards/PVT Transcatheter AVRby Antegrade and Retrograde Approach Alain Cribier – 2002/2003
Mechanical heart valve – 1960
Surgery
Transvascular
1960 20021970 2004 2006
CoreValve PURE Percutaneous AVRSerruys, DeJaegere, Laborde October 12, 2006
Edwards/PVT Transapical Beating Heart AVR
Webb, Lichtenstein – November 29, 2005
CoreValve Percutaneous AVRWITHOUT cardiac assist or pacingGrube, Gerckens – November 6, 2006
Evolution of Aortic Valve Replacement
SAVR
tAVR PAVR
TAVR
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TAVI
Two different types of valves
Marie Erpicum – Perfusionniste Département de chirurgie cardiovasculaire et thoracique - CHU de
Liège
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Edwards SAPIEN™ THV
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• The first human implant was performed in 2002
• The initial prosthesis developed by Cribier was made of equine pericardium
• The currently used Edwards PAV, is a tri-leaflet bioprosthesis that is made of bovine pericardium
• Two different dimensions 23 and 26 mm, that can be advanced trough a 22F or a 24F percutaneous sheath
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CoreValve Revalving® (Medtronic)
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• Single layer porcine pericardium
• Tissue valve sutured to frame
• Tri-leaflet configuration
• Skirt • primary function = sealing• scalloped for flow dynamics
• Designed for transcatheter delivery
• Two sizes accommodate 90% of patients
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With differing circumferential dimensions:
▫ Largest dimension for ascending aorta contact
▫ Smallest dimension to preserve coronary blood flow
▫ Flared intra-annular dimension adapting to a range of annulus sizes
Blood flow
Self-Expanding Multi-Level Frame
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TAVI
Actual indications
Marie Erpicum – Perfusionniste Département de chirurgie cardiovasculaire et thoracique - CHU de
Liège
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TAVI
Risks and results
Marie Erpicum – Perfusionniste Département de chirurgie cardiovasculaire et thoracique - CHU de
Liège
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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n=43 (100%)
PM
Yesn=8 (18,6%)
Anterior n=7 (16,3%)
For TAVI n=1 (2,32%)
No n=35 (81,4%)
LBB after TAVI
n= 21 (48,8%)
AVB after TAVI
n= 11 (25,6%)
PM implantation n=9 (20,9%)
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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Vascular access
HemorrageHematomaIschemia
Nervous lesionVascular lesion
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OK
Manual com-
pression
Suture
Com-pression bandage
Stenting Surgery
Vascular access : Complications treatment
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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Insuffisance rénale : 2-10 %
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Chronic Renal Failure 35%
Contrast agents 257 ± 68 ml
EER post TAVI 1 case (CRF)
Medical Θ modif. With CRF 11%Without CRF 4%
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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Risque ischémie coronaire
Position aortique
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Edwards TAVI Complications
POOLED*(503 pts)
SOURCE(1038 pts)
VANCOUVER(250 pts)
PARIS(75 pts)
CA-Multictr(339 pts)
Vascular (maj)** (%) 18.5 10.6 10.3 11.8 13.1
AR >2+ (%) 10.9 4.7 5.0 5.3 7.7
Stroke (%) 4.0 2.5 3.0 4.0 2.3
New Pacemaker (%) 4.4 7.0 5.5 5.3 4.9
Renal Failure (%) 5.2 8.7 4.2 na 2.6
Coronary Obstr (%) 0.4 0.6 na 0 0
Martin B. Leon, TCT 2009
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Edwards TAVI Complications
POOLED*(503 pts)
SOURCE(1038 pts)
VANCOUVER(250 pts)
PARIS(75 pts)
CA-Multictr(339 pts)
Vascular (maj)** (%) 18.5 10.6 10.3 11.8 13.1
AR >2+ (%) 10.9 4.7 5.0 5.3 7.7
Stroke (%) 4.0 2.5 3.0 4.0 2.3
New Pacemaker (%) 4.4 7.0 5.5 5.3 4.9
Renal Failure (%) 5.2 8.7 4.2 na 2.6
Coronary Obstr (%) 0.4 0.6 na 0 0
Martin B. Leon, TCT 2009
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Rolf Fimmers, Georg Nickenig, et al., Resonance Imaging Implantation: A prospective Pilot Study With Diffusion-Weighted Magnetic Risk and Fate of Cerebral Embolism After Transfemoral Aortic Valve JACC 2010;55;1427-1432,2010.
The incidence of clinically silent peri-interventional cerebralembolic lesions after TAVI is high, whereas the incidence ofpersistent neurological impairment in elderly patients with
multiple high-risk comorbid conditions was low.
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Symptomatic stroke 6 % (3 cases)
Delays 8 months2 months Direct after TAVI
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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30-Day Adverse Events*(Site Reported & Non-adjudicated)
38
In-Training Solo Total EER
Cardiac†Death 6.4% 7.0% 6.7%Aortic Dissection 1.2% 0.5% 0.9%
Cardiac Perforation 3.0% 2.1% 2.7%Cardiac Tamponade 4.2% 2.6% 3.6%
Access Site Bleeding 3.5% 1.9% 2.9%Major Bleeding 8.2% 4.7% 6.9%
Conversion to Surgery 0.5% 1.2% 0.8%Myocardial Infarction 0.9% 0.9% 0.9%
Major Arrhythmia 16.3% 14.9% 15.7%Permanent Pacemaker 25.7% 23.9% 25.0%
Renal Failure 2.2% 2.3% 2.2%Stroke 2.2% 2.3% 2.2%
TIA 0.4% 0.4% 0.4%
Euro PCR 2009
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Tamponade 2 cases
- ventricular perforation by the temporary pacing lead (First day after TAVI)
- compressive inflammatory exsudative collection (48 hours after TAVI)
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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Surcharge pulmonaire - OAP
Risque fuite paravalvulaire
Position aortique – Implant expansible
Martin B. Leon, TCT 2009
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Edwards TAVI Complications
POOLED*(503 pts)
SOURCE(1038 pts)
VANCOUVER(250 pts)
PARIS(75 pts)
CA-Multictr(339 pts)
Vascular (maj)** (%) 18.5 10.6 10.3 11.8 13.1
AR >2+ (%) 10.9 4.7 5.0 5.3 7.7
Stroke (%) 4.0 2.5 3.0 4.0 2.3
New Pacemaker (%) 4.4 7.0 5.5 5.3 4.9
Renal Failure (%) 5.2 8.7 4.2 na 2.6
Coronary Obstr (%) 0.4 0.6 na 0 0
Martin B. Leon, TCT 2009
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With differing circumferential dimensions:
▫ Largest dimension for ascending aorta contact
▫ Smallest dimension to preserve coronary blood flow
▫ Flared intra-annular dimension adapting to a range of annulus sizes
Blood flow
Self-Expanding Multi-Level Frame
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After TAVI
1 month
AR >2 6,5% 3 %
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Vascular access
Embolism
pericardial collection
Valvular regurgitation
Aorta dissectionConduction deficit
Contrast agents
…
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Mortality
1 month 2%
1 year 13 %
2 years 17%
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TAVI
The PARTNER trial
Marie Erpicum – Perfusionniste Département de chirurgie cardiovasculaire et thoracique - CHU de
Liège
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Thank you
Marie Erpicum – Perfusionniste Département de chirurgie cardiovasculaire et thoracique - CHU de
Liège
Marie ErpicumPerfusionnist
Cardiovascular & Thoracic surgery departmentCHU of Liege