Presentación de PowerPoint - SOLACI · Total number of valves implanted by size, 2011-2014...
Transcript of Presentación de PowerPoint - SOLACI · Total number of valves implanted by size, 2011-2014...
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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%
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Coronariografía:
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Ventriculograma + Aortograma:
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Ecocardiograma:
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Ecocardiograma:
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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
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Etiology of Aortic Regurgitation
SEVERE AI SECONDARY TO LVADIMPLANTS INCREASING
EXPONENTIALLY.
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MSCT:
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MSCT: PERIMETRO 87 mm
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Acceso Vascular Derecho:
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Acceso Vascular Izquierdo:
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JenaValve
SymetisValve
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COREVALVE:
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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%)
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NO PPM
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PPM: 120 LPM PPM: 140 LPM
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RECAPTURA DE LA VALVULA
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MCP 160 LPM
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NUNCA LIBERAR SIN MARCAPASOS
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PPM OFF
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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
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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
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Predictors of ComplicationsEarly Vs Late Experience
Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Sung-Han Yoon. DEC 2017
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• 72 años
• Mujer
Antecedentes:
• Artritis reumatoide severa
• FEVI: 30%
• 6 meses evolución falla cardiaca con progreso a estadio IV
• Endocarditis Marantica
CASO N°2:
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MSCT: PERIMETRO 79mm
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Evolut R 29
PPM: 120 LPM PPM: 140 LPM
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PPM: 140 LPM PPM: OFF
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NUNCA SUSPENDER ARREO CON MARCAPASOS EN EL MOMENTO DE LA LIBERACION DEFINITIVA
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• 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:
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Aortic Regurgitation
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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
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Aortic Regurgitation
Angulo: 61°
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No PPM PPM 130
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PPM 150
Critical moment to release the device
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Second Attempt
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Third AttemptOscillatory Movements of the DeviceAumento de PPM a 170 lpm
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Mantaining PPMEven after last 1/3 of reléase PPM
170
Final Result
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Challenges in treatment of non-calcified AR
Insufficient anchoring
Dislocation / embolisation
Residual AR
Annular rupture
Concomitant aortic dilation
Large annuli
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PHASES FOR DEVICE RELEASE
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First Phase: Absence of Displacement, Peacemaker not needed (stable system).
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No PPM PPM 130
First Phase: Should start peacemaker at 130 to 150 bpm.
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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.
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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)
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Fourth phase: No movement, achieved at rates between 180 - 200 BPM.
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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:
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ECHO
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DIAGNOSTIC ANGIOGRAPHY
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CORONARY
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CT
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Multiple Options for Vascular Access
Direct aortic
Subclavian/Axillary
Transapical
Transfemoral
Carotid
Common IliacRPA
IVC to Aorta Entry
Transeptal Supranavicular
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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
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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
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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.
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Angle: 86°
AREA: 44 mm
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Perimeter: 83,5mmArea: 54,5mm
DIAMETER: 15,4 cms2,89 cms
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PROCEDURE
WIRE IN HORIZONTAL PLANE, NOT BELLY UP.
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PULL BACK
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LIBERACION CON PPM A 120
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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:
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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:
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Coronary Angiography, Ventriculogram and Aortogram
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Valve Deformation During Snare
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