Replacement in an Intermediate Risk Patient Adolfo Lpez Campanher, - - PowerPoint PPT Presentation

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Replacement in an Intermediate Risk Patient Adolfo Lpez Campanher, - - PowerPoint PPT Presentation

Nov 12, 2023 149 likes •338 views

Transcatheter Aortic Valve Replacement in an Intermediate Risk Patient Adolfo Lpez Campanher, MD Disclosure Statement of Financial Interest I, Adolfo Lpez Campanher DO NOT have a financial interest/arrangement or affiliation with one or

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Transcatheter Aortic Valve Replacement in an Intermediate Risk Patient

Adolfo López Campanher, MD

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I, Adolfo López Campanher DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Disclosure Statement of Financial Interest

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INTRODUCTION

  • Aortic valve stenosis is the most common form of

valvular heart disease in the elderly population.

  • Approximately 30-40% of elderly patients with

severe, symptomatic aortic valve stenosis are deemed ineligible for surgery because of high perioperative risk so transcatheter aortic valve replacement (TAVR) is indicated.

JACC Cardiovasc Interv 2013;6(5):443-51

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INTRODUCTION

  • Physicians are now selecting “lower” surgical

risk patients to undergo TAVR.

  • It is unclear whether “off-label” TAVR treatment
  • f patients considered intermediate-surgical-risk,

(Society

  • f

Thoracic Surgeons scores: 3-8%), would effectively compete in safety and efficacy with surgical aortic valve replacement (SAVR).

JACC Cardiovasc Interv 2013;6(5):443-51

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CASE DESCRIPTION

  • 75 y.o. male.

History of myelodysplastic syndrome, hypertension and congestive heart failure. Progressive shortness of breath at present time with minimal exertion.

  • Severely calcified aortic stenosis with an Aortic valve

area by continuity ecuation of 0.4 cm2, mean pressure gradient of 61 mmHg and mild aortic reagurgitation. Left ventricular ejection fraction of 64%.

  • Surgery Risk Score: Intermediate with STS Score of 4.
  • Heart Team: TAVR and SAVR options were presented

to the patient. Patient chose TAVR.

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Surgery Risk Score

Procedure Name Isolated AVRepl Risk of Mortality 4.156% Morbidity or Mortality 23.776% Long Length of Stay 10.001% Short Length of Stay 25.572% Permanent Stroke 1.468% Prolonged Ventilation 16.686% DSW Infection 0.180% Renal Failure 6.988% Reoperation 9.510%

CASE DESCRIPTION

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Transesophageal echocardiogram was performed to measure the aortic annulus (1), valsalva sinus (2), sinotubular junction (3) and ascending aorta (4).

1 2 3 4

CASE DESCRIPTION

2.1cm 3.3 cm 2.5m 3.1cm

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CT scans measurements A: Aortic Annulus: 18x25 mm B: Sinus of Valsalva: 33x33 mm C: Ascending aorta 32x30 mm A B C

CASE DESCRIPTION

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Reconstructed multidetector computed tomographic images of the abdominal aorta and its pelvic branches and of the subclavian artery.

CASE DESCRIPTION

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Angiogram of the aorta and coronary angiography showing moderate stenotic lesion of the Left Circunflex artery.

CASE DESCRIPTION

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Angiogram of the aorta and coronary angiography showing moderate stenotic lesion of the Left Circunflex artery.

Annulus: 23 mm Sinus of Valsalva: 32 mm Sinotubular junction: 25 mm Ascending aorta: 34 mm

CASE DESCRIPTION

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  • The intervention was performed under general anesthesia

and mechanical ventilation.

  • A temporary pacing lead was advanced in the right ventricle

through the right femoral vein.

  • A 6F

pigtail catheter was inserted for hemodynamic monitoring and landmark aortic angiography through the left femoral artery.

  • 6F sheath was then inserted into the right femoral artery. A

0.035 straight-tipped guidewire was placed in the LV using a left Amplatz (Boston Scientific) catheter.

  • Then a Cook 30-cm Check-Flo Performer 18F introducer

(William Cook) was inserted over an Amplatz super stiff guidewire.

CASE DESCRIPTION

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  • Native

aortic valve was predilated with a Nucleus balloon 22-40 mm (NuMED) under rapid pacing.

CASE DESCRIPTION

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A Nº29 mm self-expandable CoreValve Revalving prosthesis (Medtronic Inc), was then introduced and implanted under angiographic and fluoroscopic guidance over the super-stiff wire, with immediate improvement of the hemodynamic status.

CASE DESCRIPTION

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  • Immediately after CoreValve

deployment, ascending aorta angiography was performed.

  • Vascular

closure was performed using Prostar XL percutaneous vascular surgical system (Abbott Vascular).

CASE DESCRIPTION

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CLINICAL EVOLUTION

  • The patient developed complete AV block so after 2

days permanent pacemaker was implanted.

  • Hospital discharge:

4 days after TAVR without any

  • ther complication.
  • After

10 days

  • f

discharge Transthoracic Echocardiogram was performed showing aortic valve area by continuity ecuation as 1.7 cm2, mean pressure gradient across aortic valve of 6 mmHg, mild aortic regurgitation and left ventricular ejection fraction of 66%.

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CLINICAL EVOLUTION

  • After

3 months

  • f

discharge, Transthoracic Echocardiogram: aortic valve area by continuity ecuation as 1.5 cm2, mean pressure gradient across aortic valve of 10 mmHg, mild aortic regurgitation and left ventricular ejection fraction of 65%.

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CO CONCL NCLUSIO USION

  • Patients with severe aortic stenosis considered

at intermediate surgical risk are now being evaluated for TAVR.

  • Currently, there are no data about the clinical
  • utcomes of TAVR compared with SAVR among

such patients.

  • Randomized clinical trials comparing these 2

strategies in such patients are warranted.

JACC Cardiovasc Interv 2013;6(5):443-51