Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are...
Transcript of Valve in Valve: που βρισκόμαστε σήμερα? · •85.000 heart valve prostheses are...
Valve in Valve: που βρισκόμαστε
σήμερα?
Κ. Αγγέλη
Αν.Καθηγ. Καρδιολογίας
Α. Πανεπ. Καρδιολογική Κλινική
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
TTE
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
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)
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)
• 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.
Modes of Bioprosthetic Valve Failure
Singh et al, J Am Coll Cardiol 2019;73:1707–18
• 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%).
Management of prosthetic valve dysfunction
ESC Guidelines on VHD 2017, European Heart Journal (2017) 38, 2739–2791
Stented Bioprostheses
Stentless Bioprostheses
Each valve is unique!!
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
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
High Gradients
Lower gradient with supra-annular leaflets
Dvir et al. JAMA 2014; 312-162-70
High Gradients
High implant give lowest gradient
Simonato et al. Circ Cardiovasc Interv 2015
High implantation results in larger EOA!
Simonato et al. VIVID Registry. Eurointervention 2016
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
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
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
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
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
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.
MITRAL VALVE
Paradis, J-.M. et al. J Am Coll Cardiol. 2015; 66(18):2019–37.
The ideal prosthetic valve for MV disease
Maisano et al, Eur Heart J. 2015 Jul 7;36(26):1651-9
Challenges For Transcatheter MV prosthesis Development
Regueiro, A. et al. J Am Coll Cardiol. 2017;69(17):2175–92.
Access during mitral ViV /ViR procedures
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!!
Blanke et al, JACC Cardiovasc Imaging. 2017 Apr;10(4):482-485
Workflow:
Concept of the Neo-LVOT
TRICUSPID –PULMONARY POSITION
Available valves
Melody valve - Medtronic Sapien 3 and Sapien XT - Edwards
Eicken et al, Cardiovasc Diagn Ther 2018;8(6):765-770
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
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
Complex CHD
RVOT disorders
Available valves
Seong-Ho Kim et al, Korean J Pediatr 2017;60(8):237244
For native RVOT
diameters
>26-27mm
Challenging
procedure
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.
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.
Conclusions