ΕΠΙΠΛΟΚΕΣ ΚΑΙ ΑΝΤΙΜΕΤΩΠΙΣΗ ΤΟΥΣ ΜΕΤΑ ΑΠΟ TAVR.

ΕΙΝΑΙ ΑΝΑΓΚΑΙΟ ΤΟ ΥΒΡΙΔΙΚΟ ΧΕΙΡΟΥΡΓΕΙΟ?

Ματθαίος Παναγιώτου MD FETCSΔιευθυντής καρδιοχειρουργικής

METROPOLITAN HOSPITAL

ΠΑΝΕΛΛΗΝΙΑ ΣΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΣΙΑΣ EKE ΘΕΣΣΑΛΟΝΙΚΗ 2017

TRANSCATHETER AORTIC VALVE IMPLANTATION

• TAVR evolved from an experimental procedure to clinical routine

• This has created a strong drive to perform TAVR not only in specialized centers but also in any interventional unit.

RAISED QUESTIONS • Is TAVI similar or better than SAVR in patients at high

risk?

• Is the adoption of TAVI justified for patients at lower surgical risk?

• Do we need a surgical support?

• Is a ‘flying’ surgical team sufficient to cover complications during and after TAVR?

• Is a Hybrid theater necessary ?

HYBRID OPERATING THEATER

A surgical theater that is equipped with advance medical imaging devices such as fived C-arms, ct –scanners , MRI scannersIdeally situated next to other surgical facilities , with a size of 70 square meters to accommodate a team of 8 to 20 people: anesthesiologists ,surgeons, cardiologists,, ,nurses, technicians, perfusionists, support team from device companies etc.

TAVR Procedural complications

• Access –site related complications • Valve embolization ( aortic, left ventricle)• Central valvular aortic regurgitation• Paravalvular aortic regurgitation• Complete heart block• Stroke (Ischemic, hemorrhagic• Coronary occlusion • Annular rupture• Ventricular perforation• Shock , hemodynamic collapse

Access site –related complications

VASCULAR INJURY (1.9-%-34%)

Dissection ,perforation,occlusionProstar failure (7.1%)

CENTRAL VALVULAR AORTIC REGURGITATION

• Prosthesis underexpansion or rupture

• Malfunctioning leaflet damage during crimping or implantation

• Usually self-limited

• Gentle probing of leaflets with a soft wire or catheter

• Delivery of a second TAVR device ( valve-in-valve)

PARAVALVULAR AORTIC REGURGITATION ≥ grade 2(1-47%)

• Post-deployment balloon dilatation

• Repositioning of valve if low (recapture , snare)

• Delivery of a second TAVR device

• Percutaneous vascular closure devises(Amplatzer vascular plug)

• SAVR

ACUTE CORONARY OCCLUSION (0.6-4.1%)

• Low –lying (≤ 10mm) coronary ostia.

• Extensive annular calcification

• Small aortic root ( sinuses of Valsalva of similar or even smaller diameter of aortic annulus)

• PCI ( easier if coronaries already wired before valve implantation)

• CABG

• Complete heart block (2-33%)

– Transvenous pacing with conversion to PPM if neaded

• Annular rupture (0.8-1.3%)

– Reverse anticoagulation

– Surgical repair

– Pericardial drainage

• Stroke ischemic/hemorrhagic (≤ 10%)– Catheter based mechanical embolic

retrieval for large ischemic CVA

– Conservative

• Bleeding /hemorrhage

– Treat sourse if feasible

– Transfusion

– Reversal of anticoagulation

ACUTE MITRAL VALVE INJURY

• In deep implantation-impinging upon mitral curtain

• Uncommon

• Most likely with the TA-TAVI

• Some cases of gradual erosion of the anterior leaflet

VENTRICULAR PERFORATION

• Reverse anticoagulation

• Surgical repair

• Pericardial drainage

VALVE DISLOCATION EMBOLIZATION TO AORTA OR LEFT VENTRICLE (3-11%)

• Recapture or deploy in descending aorta if still attached to delivery system

• Valve in valve

• Endovascular (snare)

• SAVR and extraction

TAVI -Heart team approach

Other TAVI complications

• Acute renal failure requiring renal replacement therapy (1-6%)

• Prosthesis- related endocarditis (0.4-1.1%)

• Transcatheter valve thrombosis (7%)

Sudden and unexplained hypotension during TAVI =

The earliest indication of a major complication

EXCLUDE Retroperitoneal bleeding

Aortic dissection or Aortic annulus –root rupture

Pericardial tamponade

Coronary ostial obstruction

Acute severe aortic regurgitation

Shock-Hemodynamic collapse

• Assess and treat underling cause

• Inotropic support

• Mechanical circulatory support

• CPB

Leipzig Heart Center 7- year single center experience

• 2287 pts : ( 1523 TF, 752 TA, 12 Tao)• Mean age : 84.5±16.3• Fem 84%

• 245 ( 10.7%) required surgical treatment due to major complications

• 42 (1.8%) conversion to full sternotomy• 27 (1.2%) depended on the short –term use of heart- lung machine• 85 ( 3.7%) vascular complications /surgical interventions• 54 ( 2.4%) a thoracotomy within their initial stay• 15 (0.7%) required a cardiac reoperation

Outcome of patients after emergency conversion from TAVR to surgery

• 2 of 8 died in the Hybrid OR• 3 of 8 died in the surgical OR• 6 of 8 died in the catheterization -laboratory

• Hein R et al. Eurointervention 2013;9:446-51

SUGESTIONS- CONCLUSIONS

• Cardiac anesthesiologist

• General anesthesia

• Primed ECC machine for the difficult cases

• Present , active ,experienced and involved cardiac surgery team

• The procedure should be done ideally in a hybrid theater , so the conversion of a TAVI -catastrophe to an emergency surgical procedure can be done immediately

ΣΑΣ ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ

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