kerckhoff herz- und thoraxzentrum transcatheter/hybrid aortic valves in the young prof. dr. mirko...
Post on 22-Dec-2015
230 Views
Preview:
TRANSCRIPT
KERCKHOFF HERZ- UND THORAXZENTRUM
Transcatheter/Hybrid Aortic Valves in the Young
Prof. Dr. Mirko DossProf. Dr. Mirko Doss
Kerckhoff Klinik, Bad NauheimKerckhoff Klinik, Bad Nauheim
KERCKHOFF HERZ- UND THORAXZENTRUM
AVR vs TAVR Implants
0
1.000
2.000
3.000
4.000
5.000
6.000
7.000
8.000
9.000
10.000
94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
ohne kathetergeführte Eingriffe
KERCKHOFF HERZ- UND THORAXZENTRUM
Indications for AVR in the Young
• Congenital AV diseaseCongenital AV disease
• Rheumatic feverRheumatic fever InterventionIntervention
• EndocarditisEndocarditis Repair Repair
• TraumaTrauma
• Degenerative disordersDegenerative disorders AVR AVR
• Significant valve destructionSignificant valve destruction
• Failed repairFailed repair
• Failed interventionFailed interventionRisk
KERCKHOFF HERZ- UND THORAXZENTRUM
Optimal substitute for AVR
•Readily available in different sizesReadily available in different sizes
•Excellent hemodynamic performanceExcellent hemodynamic performance
•Growth potential Growth potential
•Non-immunogenicNon-immunogenic
•Minimal thrombo-embolismMinimal thrombo-embolism
•Low structural valve degeneration incidenceLow structural valve degeneration incidence
KERCKHOFF HERZ- UND THORAXZENTRUM
Transcatheter procedures in the young
Melody Pulmonary ValveMelody Pulmonary Valve
Bovine jugular veinBovine jugular vein
Platinum Iridium framePlatinum Iridium frame
KERCKHOFF HERZ- UND THORAXZENTRUM
Available Sutureless Prostheses
Enable (Medtronic)Enable (Medtronic)
Perceval (St Jude)Perceval (St Jude)
Intuity (Edwards Lifesciences)Intuity (Edwards Lifesciences)
KERCKHOFF HERZ- UND THORAXZENTRUM
Available transcatheter prostheses
Device Status Features
JENAVALVE(Jenavalve)
CE - TADevel. –TF
- anatomical orientation- partial repositioning
ENGAGER(Medtronic)
MC trial -TA no TF
- anatomical orientation- partial repositioning
ACURATE (Symetis)
CE - TAClin.trial –TF
- anatomical orientation- partial repositioning- intuitive positioning
PORTICO (SJM)
Clin.trial - TFDevel. - TA
- partial repositioning
SAPIEN 3 (Edwards)
Clin. Trial
-TF+TA- PV leak prevention
KERCKHOFF HERZ- UND THORAXZENTRUM
Transcatheter vs Sutureless AVR
KERCKHOFF HERZ- UND THORAXZENTRUM
Access routes for the young
2 cm
5 – 5.5 cm
Transapical Transfemoral Transaortic
KERCKHOFF HERZ- UND THORAXZENTRUM
TA: get as minimally invasive as TF
Percutaneous TA access & closure:
CardiApex
(1) small incisions + non rib spreading approach
(2) Validated access & closure devices
(3) Truly percutaneous? => Imaging!
KERCKHOFF HERZ- UND THORAXZENTRUM
Edwards Sapienexample: SAPIEN 3
KERCKHOFF HERZ- UND THORAXZENTRUM
TA- ACURATE (2011) Symetis
KERCKHOFF HERZ- UND THORAXZENTRUM
TA- Engager Medtronic
KERCKHOFF HERZ- UND THORAXZENTRUM
TAVR Complications
• Paravalvuar leakageParavalvuar leakage
• AV BlockAV Block
• MigrationMigration
• Leaflet dysfunctionLeaflet dysfunction
• Annulus rupturAnnulus ruptur
• Dissection/ perforationDissection/ perforation
• Coronary obstructionCoronary obstruction
• Mitral valve dysfunctionMitral valve dysfunction
KERCKHOFF HERZ- UND THORAXZENTRUM
TAVI
ResultsResults
KERCKHOFF HERZ- UND THORAXZENTRUM
Cohorte B Mortality
KERCKHOFF HERZ- UND THORAXZENTRUM
Cohorte A Mortality
Echocardiographic Findings (AT)Echocardiographic Findings (AT)
Numbers at RiskNumbers at Risk
TAVRTAVR 301301 269269 223223 210210 139139
AVRAVR 290290 224224 162162 151151 110110
Val
ve A
rea
(cm
2 )
TAVR
AVR
p = 0.002 p = 0.003 p = 0.16p = 0.001
Echocardiographic Findings Echocardiographic Findings Mean and Peak Gradients (AT)Mean and Peak Gradients (AT)
Numbers at RiskNumbers at Risk
TAVRTAVR 307307 275275 233233 218218 144144
AVRAVR 295295 228228 168168 155155 112112
Gra
dien
t (m
mH
g)
Peak Gradient - TAVR
Mean Gradient - TAVR
Peak Gradient - AVR
Mean Gradient - AVR
Paravalvular AR and MortalityParavalvular AR and MortalityTAVR Patients (AT)TAVR Patients (AT)
None - Trace
Mild - Moderate - Severe
Months Post Procedure
Mor
talit
y
Numbers at RiskNumbers at Risk
None-TrNone-Tr 167167 149149 140140 126126 8787 4141 1616
Mild-Mod-SevMild-Mod-Sev 160160 134134 112112 101101 6464 2626 1212
29.5%
14.5%
39.5%
24.8%
HR [95% CI] =2.01 [1.38, 2.92]
p (log rank) = 0.0002
Total AR and MortalityTotal AR and MortalityTAVR Patients (AT)TAVR Patients (AT)
Months Post Procedure
Mor
talit
y
Numbers at RiskNumbers at Risk
None-TrNone-Tr 135135 125125 115115 101101 6868 3131 1111
MildMild 165165 139139 121121 111111 7171 3333 1616
Mod-SevMod-Sev 3434 2525 2222 1919 1515 66 22
None - Trace
Mild
Moderate - Severe 50.7%
26.3%
33.4%35.3%
12.7%
26.2%
p (log rank) < 0.001
GARY
Christian W. HammKerckhoff Heart and Thorax Center Bad Nauheim and
Medical Clinic I, University of Giessen, Germany
One-year outcomes of transcatheter aortic valve implantation in 9.111 consecutive patients
C. W. Hamm, H. Möllmann, F.W. Mohr, A. Beckmann, F. Beyersdorf, J. Cremer, H.-R. Figulla, G. Heusch, D. Holzhey, K.-H. Kuck, R. Lange,
T. Meinertz, T. Neumann, R. Zahn, K. Papoutsis, S. Sack, S. Schneider, G. Schuler, A. Welz, T. Walther for the GARY-Executive Board
German Aortic Valve RegistrY
KERCKHOFF HERZ- UND THORAXZENTRUM
TAVI Valve Type
transapicaltransapicaltransvasculartransvascular
n = 2.632 n =6.479
Medtronic55.9%
Edwards41.3%
Others2.8%
Others2.3%JenaValve
6.1%
Edwards79.1%
Medtronic3.5%
Symetis9.0%
CoreValve™
SAPIEN™
SAPIEN™
Engager™
ACURATE™
™
KERCKHOFF HERZ- UND THORAXZENTRUM
1-year follow-up: Stroke
1-year follow-up: interviewed patientsStroke
1,7%
2,3%2,0% 1,8%
1,3%
2,8%2,1%
1,8%
0%
1%
2%
3%
4%
5%
without CABG with CABG transvascular transapical
Minor StrokeMajor Stroke
TAVISurgical AVR
n = 5421 n = 2718 n = 1782 n = 715
KERCKHOFF HERZ- UND THORAXZENTRUM
GER 2011Mandatory AQUA Quality assessment
AKL Score(Risikogruppen)
Conv. AV Surgeryexpected observed
T-AVIexpected observed
0 - <3% 1,62 % 1,54 % 2,31 % 3,32 %
3 - <6% 4,03 % 3,18 % 4,35 % 5,44 %
6 - <10% 7,54 % 9,91 % 7,65 % 7,09 %
≥ 10% 20,22 % 18,7 % 17,99 % 13,94 %
Courtesy of Prof. Welz
lower than expected mortality higher than expected mortality
KERCKHOFF HERZ- UND THORAXZENTRUM
Conclusions from GARY
Large scale registry on surgical & TAVI procedures, all comers
Excellent 1-year follow-up (98%) Continuous increase in mortality after hospital
discharge, predominately in high risk groups.
Surgical AVR better in low / intermediate risk
TAVI and surgical AVR equal in highest risk groups
KERCKHOFF HERZ- UND THORAXZENTRUM
Conclusion
Less invasive procedures are the future
In low risk consider suture less AVR
In high risk consider TAVR
TA: The FRONT DOOR approach
KERCKHOFF HERZ- UND THORAXZENTRUM
Thank you for your attention!
m.doss@kerckhoff-klinik.de
KERCKHOFF HERZ- UND THORAXZENTRUM
no personal financial disclosures
KERCKHOFF HERZ- UND THORAXZENTRUM
no personal financial disclosures
KERCKHOFF HERZ- UND THORAXZENTRUM
no personal financial disclosures
KERCKHOFF HERZ- UND THORAXZENTRUM
no personal financial disclosures
top related