Just Another Crazy TAVI Case...
Transcript of Just Another Crazy TAVI Case...
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Horst Sievert, Sameer Gafoor,
Laura Vaskelyte, Ilona Hofmann, Stefan Bertog,
Predrag Matić, Markus Reinartz, Kolja Sievert
CardioVascular Center Frankfurt - CVC,
Frankfurt, Germany
Just Another Crazy TAVI Case...
ICI 2015 Tel Aviv, Israel, Dec 13-15, 2015
.
.............min
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Physician name Company Relationship
Horst Sievert Abbott, Access Closure, AGA, Angiomed, Aptus,
Atrium, Avinger, Bard, Biosense Webster, Boston
Scientific, Bridgepoint, Carag, Cardiac
Dimensions, CardioKinetix, CardioMEMS,
Cardiox, Celonova, CGuard, Coherex, Contego,
Covidien, CSI, CVRx, EndoCross, ev3,
FlowCardia, Gardia, Gore, GTIMD Medical,
Guided Delivery Systems, Hemoteq, InSeal
Medical, InspireMD, Lumen Biomedical, HLT,
Lifetech, Lutonix, Maya Medical, Medtronic, NDC,
Occlutech, Osprey, Ostial, PendraCare, pfm
Medical, Recor, ResMed, Rox Medical,
SentreHeart, Spectranetics, SquareOne, Svelte
Medical Systems, Tendyne, Trireme, Trivascular,
Valtech, Vascular Dynamics, Venus Medical,
Veryan, Vessix
Consulting fees,
Travel expenses,
Study honoraria
Cardiokinetix, Access Closure, Velocimed, Lumen
Biomedical,
Coherex, SMT
Cook, St. Jude Medical
Stock options,
Stocks
Grant Research Support
Disclosures
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CardioVascular Center Frankfurt CVC
TAVI
• Has become a routine procedure
• Access problems < 5%
• Surgeons don't wont to give direct stand-
by anymore
- "you will do it right"
• And nevertheless - always good for a
complication session
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On 02.11.2015 17:51, Arik Finkelstein wrote:
Dear friends.
We are all going to share an outstanding and exciting "My
crazy TAVI case" session during the ICI meeting in Tel Aviv.
Each presentation will be 7 minutes followed by a 5 minutes
discussion.
Please, send my your case title, so we can put it into the
program.
Looking forward to see you all in Tel Aviv,
Best,
Arik
How this presentation evolved
Something
is wrong!
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On 02.11.2015 17:51, Arik Finkelstein wrote:
Dear friends.
We are all going to share an outstanding and exciting "My
crazy TAVI case" session during the ICI meeting in Tel Aviv.
Each presentation will be 7 minutes followed by a 5 minutes
discussion.
Please, send my your case title, so we can put it into the
program.
Looking forward to see you all in Tel Aviv,
Best,
Arik
How this presentation evolved
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From: Horst Sievert [mailto:[email protected]] Sent: Sunday, November 15, 2015 1:57 AM To: Arik Finkelstein Subject: Re:
7 min only?
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On 15/11/15 06:10, Arik Finkelstein wrote:
Dear Horst.
This is formal, but like last year, you are not
going to be limited…
Do you have a title to your case?
Best,
Arik
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From: Horst Sievert [mailto:[email protected]] Sent: Sunday, November 15, 2015 12:00 PM To: Arik Finkelstein Subject: Re:
So I am not absolutely limited to 7 min?
Regarding the title, I will have to work on
it. The problem is that I do not have crazy
cases - I have only complications :-(
Horst
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On 15.11.2015 10:59, Arik Finkelstein wrote:
Dear Horst.
•You are not absolutely limited and absolutely
not limited…
•Complications and crazy are synonyms…
•The main issue is that it will be something that
the audience can learn from
Best,
Arik
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Subject: Re:
Date: Sun, 15 Nov 2015 22:58:45 +0100
From: Horst Sievert <[email protected]>
To: Arik Finkelstein <[email protected]>
perfect - so I have 15 min
- Thank you very much
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CardioVascular Center Frankfurt CVC
Warning
• This is not one of these "funny"
complications
• Not one of those where the operator
ends up to be a hero
• One of the most severe complications I
ever had
• Patient expired
• But may be it helps to avoid this kind of
complications in the future
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Self expanding Edwards Sapien Balloon
expandable
CoreValve Sapien
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Self expanding
CoreValve • Disadvantages
- Higher pacemaker rate
- Access to coronary
arteries may be limited
occasionally
• Advantages
- Exact measurements
are not as important as
with Edwards Sapien
- Lower profile
• If used without sheath
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Self expanding
CoreValve
- Can be pulled back into
the ascending aorta
even after release
- Slow deployment
instead of "one shot"
- No need for rapid pacing
- Can be partially
repositioned before
release
- Can be completely
removed before release
• Advantages
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Self expanding
CoreValve
- Some typical Edwards
Sapien complications
almost never occur:
• Annulus rupture
• Valve embolisation into
the LV
• Obstruction of the
coronaries
• Dissection of the
ascending aorta
• Advantages
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Now you know that the CoreValve
is much more safe and reliable
than the Edwards Sapien ...
... and some of you may feel bad
that they do not have the
CoreValve available
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CardioVascular Center Frankfurt CVC
Patient History
• 85 yrs, female
• High-grade aortic valve stenosis
• Progressive dyspnea (NYHA IV),
pulmonary hypertension
• COPD
• Hyperthyreosis
• Immunocytoma (diagnosed 1995)
• EuroSCORE 30
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Clinically a clear
TAVI indication!
Let's move on!
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CardioVascular Center Frankfurt CVC
ECG
• Sinus rhythm
• Incomplete right bundle branch
block
• Heart rate: 80/min
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CardioVascular Center Frankfurt CVC
TTE • LV
- EF 56%
- Hypertrophy (septum 17mm)
• Aortic valve
- AV peak/mean gradient: 92/62 mmHg
- AVA 0.6 cm2
- Mild AR
• Mitral valve: moderate MR
• Tricuspid valve: PAPsyst 50mmHg
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Looks good!
Can we move on?
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CardioVascular Center Frankfurt CVC
TEE
• LVOT 21 mm
• annulus 22 mm
• sinotubular junction
24 mm
• ascending aorta
33mm
• Hight of sinus
valsalva 15.5mm
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CardioVascular Center Frankfurt CVC
LCA (LAO)
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CardioVascular Center Frankfurt CVC
LCA (RAO)
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CardioVascular Center Frankfurt CVC
RCA (LAO)
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CardioVascular Center Frankfurt CVC
RCA (RAO)
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CardioVascular Center Frankfurt CVC
Aortogram (LAO)
33.5 mm
24.4 mm
28.4 mm
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CardioVascular Center Frankfurt CVC
Aortogram (ap)
10.9 mm
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CardioVascular Center Frankfurt CVC
Aortogram, iliac
8.7 mm 8.6 mm
"A little bit of kinking on the left side"
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Looks good!
Can we move on?
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CardioVascular Center Frankfurt CVC
Suitable for
Edwards Sapien ...
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CardioVascular Center Frankfurt CVC
... but also a good
CoreValve case
• 22mm annulus 26mm valve
- Annulus > 23 or 24 mm would
require a 29mm Valve
• Access right femoral because
there is less kinking
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Now ....
... can we move on?
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CardioVascular Center Frankfurt CVC
No, we can not!
We havn't done
the checklists!
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CardioVascular Center Frankfurt CVC
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CardioVascular Center Frankfurt CVC
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CardioVascular Center Frankfurt CVC
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CardioVascular Center Frankfurt CVC
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CardioVascular Center Frankfurt CVC
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And now?
Can we
move on now?
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CardioVascular Center Frankfurt CVC
5 F Sheath in the right CFA
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CardioVascular Center Frankfurt CVC
10 F Prostar left CFA
What is unexpected?
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CardioVascular Center Frankfurt CVC
• More kinking
on the left!
• So why did I
introduce the
Prostar from
the left?
• Can we move
on?
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CardioVascular Center Frankfurt CVC
22 mm Balloon
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CardioVascular Center Frankfurt CVC
Position correct?
26mm CoreValve
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CardioVascular Center Frankfurt CVC
26mm CoreValve
Too high?
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CardioVascular Center Frankfurt CVC
Can we move on?
26mm CoreValve
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• Aorta 90/50 mmHg
26mm CoreValve
Can we move on?
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CardioVascular Center Frankfurt CVC
• Aorta 90/36 mmHg
26mm CoreValve
What's wrong?
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CardioVascular Center Frankfurt CVC
22 mm Balloon
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CardioVascular Center Frankfurt CVC
Gab es hier nicht schon
Angios mit KM? Nein,
leider nicht
After post-dilatation
"Excellent!!"
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CardioVascular Center Frankfurt CVC
But it was not!
• Nausea
• Cold sweat
• BP 90/45mmHg
• Puncture site ok
• Echo: no pericardial effusion
• ECG unchanged
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CardioVascular Center Frankfurt CVC
2nd run after post-dilatation Haben Sie alle Szenen chronologisch eingefügt?
Oder fehlen welche?
Bis auf eine Szene zu Beginn der Procedur,
welche identisch mit der Szene auf PPP-Folie 31 war,
wurden alle Szenen der CD eingefügt. Die Reihenfolge
war streng chronologisch.
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CardioVascular Center Frankfurt CVC
A minute later ...
• BP < 40mmHg systolic
• Patient unconscious
• No tamponade
• ECG normal
Intubation, CPR started
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CardioVascular Center Frankfurt CVC
What had happened and
how to move on?
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CardioVascular Center Frankfurt CVC
Puncture site ok
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CardioVascular Center Frankfurt CVC
Let's look at the last run Haben Sie alle Szenen chronologisch eingefügt?
Oder fehlen welche?
Bis auf eine Szene zu Beginn der Procedur,
welche identisch mit der Szene auf PPP-Folie 31 war,
wurden alle Szenen der CD eingefügt. Die Reihenfolge
war streng chronologisch.
Left main looks obstructed?
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CardioVascular Center Frankfurt CVC
"Let's move on
and open it up"
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CardioVascular Center Frankfurt CVC
6F EBU 3.5
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CardioVascular Center Frankfurt CVC
And now?
• Intermittent CPR
• Catecholamines, ...
• IABP inserted
• IABP ineffective exchanged for
percutaneous pump
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CardioVascular Center Frankfurt CVC
Some flow in the LCA ...
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CardioVascular Center Frankfurt CVC
... but I could not get in!
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How about the RCA?
Let's have a look at the
prior cine runs
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CardioVascular Center Frankfurt CVC
• Aorta 90/36 mmHg
The first cine run after valve implantation
What's wrong?
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CardioVascular Center Frankfurt CVC
Both coronaries
are occluded!
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CardioVascular Center Frankfurt CVC
Options
• Continue with PCI attempt
- hopeless
• Snare the valve and pull it
- Difficult to snare the eylets in narrow aortic
rout
- Difficult to pull the valve if post-dilatation
has been performed
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CardioVascular Center Frankfurt CVC
Difficult Decision
• Horst Sievert: "Nalan: would you like to
move on to CABG?"
• Nalan Schnelle (cardiac surgeon): "I don't
know"
• Horst Sievert: "I don't know either"
• Nalan Schnelle: "If you tell me you can
not open it then I will move on"
"Schnelle"
means "fast" in
German
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CardioVascular Center Frankfurt CVC
Set-up in the Sankt Josefs Hospital
• TAVIs are performed in the cath lab
• Patient is prept for surgery
• Pump is filled and ready to go
• 2 OR nurses in the room
• Surgical sets are open and ready to go
• Anesthesia is in the room
• 2 cardiac surgeons are scrubbed in for
each procedure
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CardioVascular Center Frankfurt CVC
Difficult Decision
• Horst Sievert: "Nalan: would you like to
move on to CABG?"
• Nalan Schnelle (cardiac surgeon): "I don't
know"
• Horst Sievert: "I don't know either"
• Nalan Schnelle: "If you tell me you can
not open it then I will move on"
"Schnelle"
means "fast" in
German
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CardioVascular Center Frankfurt CVC
Difficult Decision
• Horst Sievert: "Move on!"
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CardioVascular Center Frankfurt CVC
Outcome
• 2 grafts implanted within a
very short time period
• But could not get off pump
• IABP ineffective
• Patient passed away on the
table
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CardioVascular Center Frankfurt CVC
Looking back:
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CardioVascular Center Frankfurt CVC
What was the initial mistake?
• Patient selection
- Aortic root rather small
• although within the limits
- Sinus valsalva short
• although within the limits on echo
(not measured on angio)
- Too much calcium?
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CardioVascular Center Frankfurt CVC
Other major mistakes
• I overlooked the RCA occlusion
• I failed to re-open the LCA
• Maybe conversion to surgery was a
mistake
- Pump + further recanalization
attempts?
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CardioVascular Center Frankfurt CVC
What was the point of no return?
• Post dilatation!
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CardioVascular Center Frankfurt CVC
What could I have done
before the point of no return?
• Snare the valve and pull it into the
ascending aorta
- Difficult decision because the RCA was
very small and the position of the valve
otherwise perfect
• Wire the LCA before post-dilatation of
the valve to keep access?
- Difficult technically and because there was
also severe AR and hemodynamics not
stable
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CardioVascular Center Frankfurt CVC
How to avoid this in the future?
• To be more restrictive in
borderline cases?
• Additional imaging (CT, ...)?
• Other advanced technology?
- Computer simulation of device
implantation?
- Rapid prototyping?
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CardioVascular Center Frankfurt CVC
Thank you!
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CardioVascular Center Frankfurt CVC
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CardioVascular Center Frankfurt CVC
Corevalve Beurteilung
-------- Original Message --------
Subject: Re: Patienten CSI
Date: Mon, 2 Jul 2012 12:40:52 +0200
From: Kuester, Frank <[email protected]>
To: Horst Sievert <[email protected]>
Hallo Herr Prof. Sievert,
Leider kann ich Sie telefonisch nicht erreichen.
Kurz zusammengefasst die Antworten auf Ihre Fragen:
Bei Habermann ist die Anatomie recht klein sie würde für eine 26mm Corevalve
in Frage kommen. Sie hat einen kleinen Sinus und viel Kalk, deshalb sollte
man auf die Koronarien achten, d.h., eventuell die Klappe etwas tiefer bzw.
Nicht zu hoch implantieren.
vielen Dank und Schöne Grüße,
Frank Kuester
TDM
Transcathetervalves
Medtronic GmbH
Mobil:0175/9354814
Am 02.07.2012 um 09:22 schrieb "Horst Sievert" <[email protected]>:
> PS: Frage zu Habermann: Hatten Sie sie auch in Holland beurteilen lassen?
>
>
>>
>>
>> On 18.06.2012 09:32, Kuester, Frank wrote:
>>> Hallo Herr Prof. Sievert,
>>> Im folgenden die Beurteilung Ihrer Patienten.
>>>
>>> Patientin Habermann, Johanna
>>> Leistengefäße OK.
>>> Annulus 19-21mm ( Echo, CT), relativ stark verkalkt.
>>> 26 mm Corevalve Implantation möglich.
>>> Vielen Dank und Schöne Grüße,
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>> Frank Kuester
>>> TDM
>>> Transcathetervalves
>>> Medtronic GmbH
>>> Mobil:0175/9354814
>>>
>>>>
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CardioVascular Center Frankfurt CVC
Thank you!