la sténose aortique tavi: indications, technique et suivi post … · 2019. 3. 19. · tavi:...
TRANSCRIPT
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La sténose aortique
TAVI: indications,
technique et suivi post
procédure
Dr. Christan Roguelov
Département Cœur Vaisseaux
Service de Cardiologie
CHUV
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BURDEN OF VALVULAR HEART DISEASESIMPORTANT PUBLIC-HEALTH PROBLEM
Nkomo VT, Lancet 2006
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DISTRIBUTION OF VALVULAR HEART DISEASESEURO HEART SURVEY
Iung B, Eur Heart J 2003
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PATIENT CHARACTERISTICSEURO HEART SURVEY
Iung B, Eur Heart J 2003
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AORTIC STENOSIS
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AORTIC STENOSISETIOLOGIES
Baumgartner H, Eur J Echocardiogr 2009
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50 % 25 %
18 %2 % 2 % 3 %
Passik CS, et al, Mayo Clin Proc 62:119, 1987
AORTIC STENOSISETIOLOGIES: PATIENTS
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50 % 25 %
18 %
2 % 2 % 3 %
48 %27 %
2 %23 %
Passik CS, et al, Mayo Clin Proc 62:119, 1987
AORTIC STENOSISETIOLOGIES: PATIENTS >70 YO
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Patients avec sténose aortique opérés
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Patients avec sténose aortique TAVI
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Patients avec sténose aortique non traités
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• ANGINE DE POITRINE
• SYNCOPE
• FATIGUE, DYSPNEE
• MORT SUBITE (rare)
STENOSE AORTIQUESYMPTOMS
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Ross J Jr, Circulation 1968
AORTIC STENOSISNATURAL HISTORY
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Brown ML, J Thorac Cardiovasc Surg. 2008
SEVERE SYMPTOMATIC AORTIC STENOSISSURVIVAL RATES AVR vs. NO AVR
Symptoms – no AVRNo symptoms – no AVR
No or Symptoms –AVR
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Définition classique de la SA sévère
Otto C et al. Circulation 1997; 95: 2262-70 Bonow R. AHA/ACC Guidelines. Circulation 2006; 48: e1-148
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Sténose aortique sévère
Diamètre de la
CCVG
Flux trans-aortique
Flux de la
CCVG
A1 = × (D/2)2
• Vitesse maximale
• Gradient maximal
• Gradient moyen
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Gradients et équation de continuité:
les discordances sont fréquentes!
• Retrospective characterization of 512 consecutive patients with
“severe AS” (AVA 50%.
N= 196
38%N= 316
62%
Mean gradient ≥40 mmHg Mean gradient
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Le gradient dépend du débit transvalvulaire
250 ml/s = typical ejection velocity corresponding to a 80 ml stroke volume ejected within 320 ms systolic time
250
Voelker W. Circulation 1995; 91: 1196
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Evaluation de la racine aortique par angio-CT
• Taille de l’anneau
• Distance anneau-coronaires
• Taille des sinus
• Pontages aorto-coronariens
• Aorte porcelaine
Kasel AM. JACC Img 2013
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CT: Evaluation vasculaire / calcifications
Distribution des calcifications Accès vasculaires
Landing zone(annulus, commissures)
→ Paravalvular leak(valve undersizing/asymmetric Ca++)
LVOT
→ Annular rupture(Oversizing/ balloon expandable)
Bulky leaflet calcification
→ Coronary obstruction(low coronaries, small sinus)
Barbanti M. Circulation 2013 Ewe SH Am J Cardiol 2011 Unbehaun A. JACC 2012
•Diameter
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Prise en charge du patient avec sténose aortique (ou autre
valvulopathie) au CHUV - Heart team - VALVE BOARD
• Identification du patient avec SA (adressé par cardiologue ou hospitalisé)
• Coordinatrice Valve board
• Organisation du bilan (1-2 jours)– Labo
– CT scan 3D, coro, echo, Doppler carotides
– Consultation gériatrie
– CPC (post colloque)
• Mail pour le cardiologue ttt et le Valve Board
• Discussion
• Décision: SAVR, TAVI, ttt médical, réévaluation après information complémentaires
• Planification et convocation
• Intervention
• Registre SWISS TAVI et suivi PMU CHUV.
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TAVITranscatheter Aortic Valve
Implantation
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17 ans d’évolution du TAVI
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17 ans d’évolution du TAVI
Transcatheter aortic valve replacement in the USA 161
Cardiologie
interventionnelle
le développement des valves aortiques percutanées aux USA, et le rôle majeur joué par les
États-Unis dans cet extraordinaire aventure « process ».
© 2012 Elsevier Masson SAS.
Background
It is now 10 years since the first human transcatheter aortic
valve replacement (TAVR), a procedure performed in Rouen,
France, in a patient with severe aortic stenosis (AS) [1].
Currently, a decade after this historic event, most TAVR
procedures performed and the majority of innovations in
the field of transcatheter valve technologies occur outside
the United States of America (USA). Nevertheless, the USA
had a major role in the development and evaluation of this
technology (Fig. 1). It could be said that although TAVR
was born in France, it matured in the USA. In the following
review, we provide data on the development of TAVR in
the USA, revealing the critical role the USA played in this
extraordinary process.
The early days
In early 2004, almost 2 years after the first human TAVR
procedure, when only a total of 17 patients had been
treated by this technology, TAVR entered into the ‘major
league’ of the industry with the purchase of a small
privately held medical technology company, Percutaneous
Valve Technologies, Inc. (PVT, Caesarea, Israel), by the
American-born Edwards Lifesciences Corporation (Irvine,
CA, USA). This transaction allowed Edwards to accelerate
the development of this breakthrough technology while
providing the needed expertise and resources to ensure suc-
cessful commercialization (Fig. 2). Several months later, at
the 2004 Transcatheter Cardiovascular Therapeutics (TCT)
Figure 1. Milestones in the development of transcatheter aortic valve devices in the USA and in Europe.
meeting held in Washington, DC, TAVR attracted major
publicity as a widely discussed topic. One of the highlights
was the live introduction of a patient 1-year post-TAVR.
Feasibility evaluation of the EdwardsSAPIEN device
The USA Food and Drug Administration (FDA) had a major
influence on the evaluation of TAVR devices. The FDA, an
agency within the United States Department of Health and
Human Services, is responsible for protecting and promoting
public health through the regulation and supervision of
numerous materials, including medical devices. The Center
for Devices and Radiological Health is the branch of the
FDA responsible for the premarket approval of all medical
devices in the USA, as well as overseeing the manufactur-
ing, performance and safety of these devices. In January
2005, the FDA conditionally approved the first feasibility
trial of the Cribier-Edwards percutaneous aortic heart
valve. Six months later, Edwards Lifesciences announced a
delay in enrolment in its percutaneous aortic heart valve
clinical feasibility trials in the USA using the antegrade
transseptal delivery, in order to incorporate the retrograde
delivery system, which at that time had already been
evaluated in several cases in Canada. The company took
this action after some USA antegrade cases demonstrated
a significant degree of clinical complexity and adverse
outcomes. However, the ‘loss’ of the antegrade transseptal
approach was rapidly replaced that year by the ante-
grade transapical approach, performed using the Ascendra
Cet article est publié en Open Access sous licence CC BY-NC-ND.
Dvir D et al. Arch cardiovasc Dis 2012; 105: 160-4
Modification de la prise en charge de la sténose aortique
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Différentes types de valves percutanées
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TAVI « work-up »
Sévérité
Faisabilité
Chirurgie vs TAVI
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STS score
STS-score
0 84Bas Intermédiaire Elevé
Evaluation du risque chirurgical d’une RVA
www.riskcalc.sts.org
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Traitement
?
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Traitement très haut
risque/inopérable ?
Traitement médical TAVI
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Leon, NEJM, 2010
PARTNER Study Design B
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Suivi à 5 ans
Kapadia, Lancet, 2015
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Traitement
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SAVR TAVR
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PARTNER 2 (STS moyen 5.8)
TAVI équivalent au RVA chirurgical
Leon MB et al. N Engl J Med 2016; 374: 1609-20
Différence significative pour sous-groupe « trans-fémoral »
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Partner 2
Death from Any Cause or Disabling Stroke(%)
STS-score = 5.8%
Leon, NEJM, 2016
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SURTAVI
Death from Any Cause or Disabling Stroke(%)
STS-score = 4.5%
Reardon, NEJM, 2017
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Nouvelles recommandations pour
les maladies valvulaires
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TAVR vs SAVR ?
Guidelines, ESC 2017
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CHIRURGIE TAVI
Risque opératoire
Contre-indications
Faisablité technique
Frailty
Futility
âge
Chirurgien
Cardiaque
Cardiologue
Invasif
Cardiologue
Non-invasif
Radiologue
Anesthésiste
Cardiaque
Gériatre
VALVE BOARD
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TAVR vs SAVR ?
Guidelines, ESC 2017
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Valve board connecté
CHUV
VALVE BOARD
Anesthésiste
Chirurgien cardiaque
Radiologues
Cardiologue interventionnel
Cardiologue imagerie
Coordinateur des valves
Gériatre
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Application iphone « Heart Valve »
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Caractéristique des patients - CHUV 2018
TOUS TF-TAVI TA/TABC-TAVI
Age (années) 82 ± 8 82 ± 8 82 ± 6
Sexe masculin (n) 43 (43%) 31 (40%) 12 (55%)
Taille (cm) 165 ± 8 165± 8 165± 9
Poids (kg) 72 ± 15 72 ±16 66 ± 15
Surface corporelle (m2) 1.7 ± 0.4 1.8± 0.2 1.7 ± 0.2
Créatinine (mcmol/l) 113 ± 78 104± 39 147 ± 148
eGFR (ml/min) 49 ± 13 50± 12 46 ± 17
Maladie coronarienne (n) 55 (55%) 42 (55%) 13 (59%)
STS-score (%) 5.9 ± 4.8 5.9 ± 5.0 6.1 ± 4.2
STS >8 : 20%
STS 4-8 : 36%
STS
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Pratiquement…
TAVI
TAVI
1. Sedation
2. Intervention = 1 h
3. Soins continus
J0
TAVI
Surveillance1. Soins continus
2. Echo tt contrôle
3. Déséquipement
4. Lever
J1 TAVI
Pacemaker+
1. Mobilisation
2. RAD/transfer
CTR
J2-5
TAVI
Pacemaker -
1. Télémètrie 48
heures
BBG/BAV
2. Mobilisation
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Various vascular access
approaches
Jones, Nature Cardiol Rev, 2017
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EDWARDS Sapien 3 - transfémorale
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TAVI: accès fémoral
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TAVI: positionnement et pre-
dilatation
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TAVI: implantation d’une valve
Edwards sapien 3
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Suivi post TAVI
1 moisVisite
échocardiographie
+ consultation
3 moisVisite
échocardiographie
+ consultation
12 moisVisite
échocardiographie
+ consultation
Cardiologue
traitant
Prophylaxie de l’endocardite
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Conclusions: TAVI
– La sténose aortique sévère est un groupe
hétérogène
• Surface, gradient et flux
– La sténose aortique sévère doit être traitée
– Le choix de traitement se décide lors un
« valve board » - équipe multidisplinaire
• < 75 ans = chirurgie
• > 75 ans = TAVI
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Merci pour votre attention