更多经皮瓣膜介入治疗循环支持

更多经皮瓣膜介入治疗更多经皮瓣膜介入治疗: 循环支持循环支持 Eric E. Roselli, MD 声明声明 Medtronic 咨询机构咨询机构 Edwards 研发者研发者 Direct Flow Medical 咨询机构咨询机构 球囊扩张瓣膜成形术球囊扩张瓣膜成形术 快速心室起搏快速心室起搏 瓣膜释放瓣膜释放 未能送入未能送入- 3 纳纳入入161名患者名患者 释释放失放失败败 n = 19 送入失送入失败败 - 9 植入成功植入成功 88.2% 23 mm Valve (55) 心心脏脏穿孔穿孔* - 3 26mm 瓣膜瓣膜 (87) 61.3% 38.7% 移位移位/栓塞栓塞 - 2 麻醉并麻醉并发发症症- 2 经股动脉经股动脉 REVIVE and REVIVAL II 操作结果操作结果 Successful Deployment n = 142 23 mm 瓣膜瓣膜 (55) 成功成功释释放放 n = 142 Slide courtesy of Susheel Kodali REVIVAL II 经心尖技术的成功性经心尖技术的成功性 87.5% 移位移位 / 栓塞栓塞 12.5% 送入失败送入失败 0 平均释放时间平均释放时间 11.7 min 平均操作时间平均操作时间 87.1 min THV 学习曲线学习曲线 成功植入百分比成功植入百分比 % Slide courtesy of T. Lefvre b a c e d 精确释放至关重要精确释放至关重要 REVIVE valve migrated into LV during CPR * One patient treated with left main stent, one patient managed medically TRAVERCE: TA Feasibility study (n=168) Implant Success 92.8 % 30-day Survival 85 % 6-month Survival 70 % Freedom from Stroke 6 mo. 95 % Freedom from MI 6 mo. 98 % off-pump 77 % Sternotomy (conversion) 7.1% (n=12) Slide courtesy of T. Walther TRAVERCE: Conversion: 7 % Malposition Low High 4 2 2 Valve migration Distal Ventricular 3 2 1 Aortic Insufficiency Central regurgitation 3+ Paravavlular leak 2+ due to annular tear Paravalvular & central regurgitation 6 2 2 2 Ascending aorta dissection 1 Mitral chordae entanglement 1 15 events in 12 patients Slide modified from Thomas Walther Lessons Learned Reoperation is not an independent predictor of mortality in conventional cardiac surgery RESCUE What is the role of circulatory support in transcatheter AVR? RESCUE Roselli, et al. Adverse events during reoperative cardiac surgery: rescue JTCVS 08 Indications for Rescue in Transcatheter AVR Hemodynamic Instability Coronary impingement Severe AI after BAV Ascending aorta or annulus injury Circulatory Support Options Full Cardiopulmonary Fem-fem bypass ECMO Biomedicus centrifugal pump Tandem heart Case 83 y/o female Severe symptomatic AS Valve area 0.6cm Severe COPD, h/o CVA, renal insufficiency, PVD, frail Underwent transfemoral AVR 23mm Hypotension did not recover Echo showed dilatation and severe LV dysfunction Is there another role for circulatory support during transcatheter AVR? Corevalve Results 91 - 97% technical success Gradients 50 5mmHg 14% 2+ AI PPM 9-25% Mortality 15% Feasibility trial 9% CE mark Registry *Population analyzed = Patients with Sapien in place and alive post-procedure (no conversion) Survival* 93.6% NYHA Class I NYHA Class II NYHA Class III NYHA Class IV 39.4% 50.5% 9.1% 1.0% MI 1.0% Stroke 3.4% Vascular Complications 7.4% The SOURCE Registry 30 Day Outcome-TF Slide courtesy T. LeFevre REVIVE II & REVIVAL II TF KM Survival if Prior CABG 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 3 6 9 12 Months past Procedure Freedom from Death 0 0 No Yes Log Rank P=0.008 93.0% 88.3, 97.7 84.6% 77.8, 91.3 79.7% 71.9, 87.6 78.3% 66.3, 90.2 69.0% 55.5, 82.6 59.5% 45.0, 74.0 number at risk 100 78 69 50 114 NO 32 29 27 16 46 YES REVIVAL II TF KM Survival by Baseline MR Freedom from Death Months past Procedure Log Rank P=0.0479 97.2% 91.8, 100 85.8% 74.2, 97.3 82.8% 70.3, 95.3 83.3% 66.1, 100 77.8% 58.6, 97.0 61.1% 38.6, 83.6 number at risk 43 28 12 8 54 In select high risk patients, there may benefit to unloading the LV with circulatory support Conclusions Transcatheter AVR has become a technically successful off-pump procedure Prime role for circulatory support is to facilitate RESCUE from life-threatening complications NYHA class, Prior CABG, and MR 2+ trend as predictors of death in TAVR There may be a role for LA-Fem partial bypass (TandemHeart) in these high risk patients June 3-5 2009 InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio /CardioCare09 www.MeetTheB Sessions will include: Aortic Disease Coronary A