Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are...

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Valve in Valve: που βρισκόμαστε σήμερα? Κ. Αγγέλη Αν.Καθηγ. Καρδιολογίας Α. Πανεπ. Καρδιολογική Κλινική

Transcript of Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are...

Page 1: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Valve in Valve: που βρισκόμαστε

σήμερα?

Κ. Αγγέλη

Αν.Καθηγ. Καρδιολογίας

Α. Πανεπ. Καρδιολογική Κλινική

Page 2: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Case 1

• 71 year-old man admitted due to progressively increasing dyspnea (NYHA class III)

• Background:

• Severe degenerative MR secondary to ruptured tendinous cord of the anterior mitral leaflet

• Severe AR

• 2007: Surgery with complex MV reconstruction

• Annuloplasty with a 25-mm circular flexible Duran ring (Medtronic, Minneapolis, Minnesota), implantation

of the ruptured tendinous cord into the anterior papillary muscle, and placement of new synthetic chordae

tendineae.

• A prosthetic metallic aortic valve (ATS Open Pivot Heart Valve 25 mm, ATS Medical, Inc. Minneapolis,

Minnesota).

Normocytic anemia accompanied by elevated indirect bilirubin and LDH levels,

suggestive of hemolytic anemia

Page 3: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 4: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 5: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 6: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 7: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

TTE

Page 8: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Case 2

• 71 years-old female admitted with heart failure symptoms (NYHA IV)

• Previous Interventions:

- 06/2016: Surgical tricuspid valve replacement with a 27-mm Epic bioprosthetic valve (St Jude Medical, Inc, St Paul, Minnesota) and implantation of a bipolar

pacemaker lead for future use

- 05/2012: Surgical mitral valve replacement with a mechanical valve

• Other Medical History:

- Atrial fibrillation, DM type II

- Pleurodesis for persistent pleural effusion

• Meds : acenocoumarol, diuretics, antidiabetic treatment

Page 9: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

71 years-old female admitted with heart failure symptoms (NYHA IV), surgical TV replacement with a 27-mm Epic

bioprosthetic valve (06/2016), surgical MV replacement with a mechanical valve (05/2012)

Page 10: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

71 years-old female admitted with heart failure symptoms (NYHA IV), surgical TV replacement with a 27-mm Epic

bioprosthetic valve (06/2016), surgical MV replacement with a mechanical valve (05/2012)

Page 11: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 12: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 13: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

• 85.000 heart valve prostheses are implanted in the United States each yearand a total 275.000 worldwide.

• The use of bioprosthetic aortic valve replacement increased from 26.7% in1998 to 50.2% in 2005.

• The major shift in the use of surgical bioprostheses, combined with theirshorter durability and the increasing life expectancy of an aging population,is expected to translate into a major increase in the incidence of patientswith surgical valve failure in the coming years.

Page 14: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Modes of Bioprosthetic Valve Failure

Singh et al, J Am Coll Cardiol 2019;73:1707–18

Page 15: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

• The mechanism of aortic bioprosthesis dysfunction are equally distributed

as predominantely stenostic, regurgitatnt, or mixed, with larger rate of

stenotic dysfunction among stented and smaller (<21mm) valves, and a

predominant regurgitatnt mechanism among stemless valves. In mitral

biprostheses, regurgitation is the predominant mechanism of valve

dysfunction (49%), followed by stenosis (22%) and combined mechanisms

(30%).

Page 16: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 17: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 18: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 19: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 20: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Management of prosthetic valve dysfunction

ESC Guidelines on VHD 2017, European Heart Journal (2017) 38, 2739–2791

Page 21: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Stented Bioprostheses

Stentless Bioprostheses

Each valve is unique!!

Page 22: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 23: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

High Gradients

Importance of true ID

• To choose the right size of TAVI device

• To avoid PP mismatch and valve dysfunction

Label size does not mean same ID!!

True ID = Stent ID- reduction due to leaflet tissue

Oversizing is bad

Incomplete expansion

Uneven expansion

Russian Doll effect

Page 24: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Ideal Position : Reference Level

Sewing ring

With Reference to the Neo-annulus = Sewing ring Where is the sewing ring?

Sewing ring marker

Stent frame marker

No marker

Page 25: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

High Gradients

Lower gradient with supra-annular leaflets

Dvir et al. JAMA 2014; 312-162-70

Page 26: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

High Gradients

High implant give lowest gradient

Simonato et al. Circ Cardiovasc Interv 2015

Page 27: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

High implantation results in larger EOA!

Simonato et al. VIVID Registry. Eurointervention 2016

Page 28: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Effect of PPM

Pibarot P, et al. VIVID Registry JACC 2018

Elevated gradients (>20mmHg) and mortality

Severe PPM of the surgical valve is associated with higher mortality after ViV

Page 29: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Risk of Coronary obstruction

Importance of true ID

Function of

• Smaller anatomy

• Narrow sinuses

• Oversizing- Stent post deflection

• Valves with leaflet outside the stent

Low High

Wide sinuses

No or low risk

Narrow Sinuses

Higher risk

Page 30: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Meta-analysis of ViV-TAVR vs Redo AV surgery

• Meta-analysis of retrospective or prospective studies that reported direct comparison of outcomes after ViV-TAVR

or redo-SAVR in patients with failed aortic bioprosthetic valves

• 4 studies with 489 patients (227 of underwent ViV-TAVR and 262 underwent redo-SAVR)

• The incidence of stroke, MI, and AKI requiring dialysis were similar.

• The rate of PPM was significantly lower in the ViV-TAVR.

30-day mortality was similar in 2 groups despite the higher operative risk in the ViV-TAVI cohort

Neupane et al, Am J Cardiol. 2018 Jun 15;121(12):1593-1600

Page 31: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Meta-analysis of ViV-TAVR vs Redo AV surgery

• Retrospective or prospective studies that reported direct comparison of outcomes after ViV TAVR or redo-SAVR in

patients with failed aortic bioprosthetic valves

• 6 studies with 498 patients (254 of underwent ViV-TAVR vs. 244 underwent redo-SAVR)

• Patients in the VIV-TAVI group were significantly older and had undergone prior CABG more frequently than those

in the redo SAVR groupNo statistically significant differences all cause mortality

in early (in hospital or 30 days) and midterm (180 days – 3 years)

Takagi et al, Thorac Cardiovasc Surg. 2019 Jun;67(4):243-250

Page 32: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Meta-analysis of ViV-TAVR vs Redo AV surgery

• Six observational studies with 594 patients (255 underwent ViV-TAVR vs. 339 underwent redo-SAVR)

No statistically significant differences in procedural, 30-day, and 1 year mortality rates

Naluri et al, J Interv Cardiol. 2018 Oct;31(5):661-671

Procedural mortality

1 year mortality

Page 33: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

The PARTNER II Trial:

Valve-in-Valve TAVR Registry

Webb JG et al. JACC 2017;69:2253-62

In high-risk patients, TAVR for bioprosthetic aortic valve failure is associated with relatively low mortality and complication

rates, improved hemodynamics, and excellent functional and quality-of-life outcomes at 1 year.

Page 34: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 35: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

MITRAL VALVE

Page 36: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Paradis, J-.M. et al. J Am Coll Cardiol. 2015; 66(18):2019–37.

Page 37: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 38: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

The ideal prosthetic valve for MV disease

Maisano et al, Eur Heart J. 2015 Jul 7;36(26):1651-9

Page 39: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Challenges For Transcatheter MV prosthesis Development

Regueiro, A. et al. J Am Coll Cardiol. 2017;69(17):2175–92.

Page 40: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Access during mitral ViV /ViR procedures

Page 41: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Predicting LVOTO in Transcatheter MV Implantation:

Concept of the Neo-LVOT

Blanke et al, JACC Cardiovasc Imaging. 2017 Apr;10(4):482-485

During surgical MVR, the anterior mitral valve leaflet is often removed to mitigate LVOTO!!

Page 42: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Blanke et al, JACC Cardiovasc Imaging. 2017 Apr;10(4):482-485

Workflow:

Concept of the Neo-LVOT

Page 43: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The
Page 44: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

TRICUSPID –PULMONARY POSITION

Page 45: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Available valves

Melody valve - Medtronic Sapien 3 and Sapien XT - Edwards

Eicken et al, Cardiovasc Diagn Ther 2018;8(6):765-770

Page 46: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

McElinney et al, Circulation 2016

152 patients

53 centers worldwide

Median age: 40 years

Bioprosthetic TV dysfunction

71% of patients in NYHA class III or

IV

Melody (n=94) or Sapien

(n=58) TVIV implantation

Median follow-up:13.3 months

VIVID Registry

Transcatheter tricuspid ViV implantation

Page 47: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

VIVID Registry

Transcatheter tricuspid ViV implantation

McElhinney DB et al, Circulation. 2016 Apr 19;133(16):1582-93

Estimated probability of survival MG across TV before and after ViV

implantation

Page 48: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Complex CHD

RVOT disorders

Page 49: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Available valves

Seong-Ho Kim et al, Korean J Pediatr 2017;60(8):237244

For native RVOT

diameters

>26-27mm

Challenging

procedure

Page 50: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

E. Sabbagk et al, Catheter Cardiovasc Interv. 2018 Jan 23.

Assessment of adequacy of valve anchoring, risk of under-expansion and LVOT obstruction

Valve anchoring – measuring the circumferential extend of MAC, reported as a percentage of the mitral annulus, as well as the location of the calcification.

Valve anchoring - measuring the surface area of the virtual valve in direct contact with the digital mitral annular calcification.

Risk of underexpansion - measuring the volume of calcium overlap.

LVOTO - visual assessment of the 3D digital LVOT model in systole with the digital valve inserted.

Page 51: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Paravalvular leak assessment

3D models simulated the location of PVL

E. Sabbagk et al, Catheter Cardiovasc Interv. 2018 Jan 23.

3D models were similar to the findings on

post procedural imaging.Visual inspection of any gaps between the virtual Sapien

valve, mitral annulus and mitral leaflets.

Page 52: Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are implanted in the United States each year and a total 275.000 worldwide. •The

Conclusions