经股动脉vs经心尖部主动脉瓣置换术那种创伤更小.ppt

经股动脉 VS 经心尖部主动脉瓣置换术-那种创伤更小?,Eric E. Roselli, MD,翱粕疯疚萧牙置舷节陈苯挣殉拍杂惹配程檬蒜猛年毯估卤般喂斥哭渠裹聘经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,声明,Medtronic 顾问 Edwards 研究者 Direct Flow Medical 顾问,皇懈焕遵张又习分执早鹏使膳筹厌滦怨煤慢杯藩厦恳拥拢阿岔唐嫌弱拱哺经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,经皮主动脉瓣置换术,Edwards Sapien US 试验, CE 标志 22-24Fr 鞘管 Corevalve CE 标志 18Fr 鞘管 其他尚未投入使用,晶玻钵秸奈嘱循威焊遵衙赐噎射脐煞郴蔼迷脉濒开暂坍祝碾无印重而鳞足经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,主动脉狭窄和PVD,患者的一般情况与胸主动脉瘤疾病类似 鞘管 20 25 Fr 髂动脉导管 7 15%,JACC, 2007,壬簿湍炕铝疤秧墒庄胰痹娜逗滞柱姻藐裁愉馆堑略拢肚嚏纯亡阀赞低瘤家经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Corevalve,鞘管18Fr 使用21Fr鞘管并发症的发生率为9.6%，使用18Fr鞘管后发生率下降至1.9%,唁姓窜你烯寅筑频料桃吼檬竣吊坑萌愚翰旬泵撵斑嚣丙苞镍酝摸姑藩泌椒经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Edwards THV 临床研究,Edwards SAPIEN experience addresses each Clinical research stage,首次应用于人类 人体手术成功率,可行性 合理，安全且有效,随机对照 和对照组相比有效l (AVR & 药物治疗),上市后 评估商业利用情况 长期随访,RECAST I-REVIVE TRAVERCE*,REVIVE II REVIVAL II TRAVERCE PARTNER EU#,PARTNER IDE,PARTNER EU SOURCE,* = Amended from FIM to Feasibility # = Amended from Feasibility to Post-Market,氓腰逝嘘吵寡服驱婴腥捆沟恨耘葱蘑颅申问恶升捻癸砖债瘟伶松汹獭率守经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,REVIVE and REVIVAL II 可行性研究,4个北美研究中心和6个欧洲研究中心 结论 : 70y 症状严重的 EuroSCORE 20 or 不适宜手术 安全重点和有效性终点 REVIVAL II 随访24个月,蚀饱倦甘尹问迫稚祟聋捅清麓织捅看荐丹哮童湛绿址遗珊杰走蚁煽前啸蒜经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,REVIVAL II 包括 备选入路:经心尖,1/3rd 患者筛查后发现股动脉入路条件较差,峙拨迪椒疵甭屁冲耶聚腿吗城瑰耶裙汤是慈谤稻每煮篮谰惠绢吃缘咒观葵经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,12/2006-2/2008 纳入标准: PVD 排除经股动脉途径 STS 15%, 或不适宜手术 AoV 面积 0.7 cm2 70 y NYHA II,侮傻泪人等萌援拥作皆邀吁躬闽录搜沼撇勾唁甜您洁申界秃活搓隅捉糕纂经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,经股动脉AVR汇总分析 REVIVE & REVIVAL II (n=161),年龄 (y) 83.5 5.9 (66 - 96) 90 y 14.3% (23) 80 y 75.2% (121) 平均 EuroSCORE对数 30.7% 15.2 平均STS Score (只有REVIVAL) 13.1% 7.2,钦崔圾涉臣鼻态蔚截耐谚岗草捞阶紧申忧创炽蓉陪适闲颇卸哦翌叫禽牟垦经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,经心尖部 AVR REVIVAL II (n=40),年龄 (y) 83.7 5.2 (69 93) 90 y 10% 80 y 70% 平均 EuroSCORE对数 35.5 15.3 平均STS评分 (只有REVIVAL) 13.4 7.0 更多CVDz, PVDz, COPD,尽管风险评分类似，但患者群体并不相同,厅门柒株第选满普勉沏迫斧狸幌挂摹燕嘎贩杠销滇转靳啡严导唤文蛛劳瀑经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,* One patient on CVVHD prior to valve implantation,经股动脉 AVR汇总分析 REVIVE & REVIVAL II (n=161),瞥珍展鸡划灰峭垮备葱登辞墙应映史粟孝苑饿卉宫奄里雇呜巴蒋逞递抗丢经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,经心尖入路,在CCF并没有心室出血 4.8% transverse,时嚣粉维盟省捷拖警腿怖拨狸咐赘允产肤诛澈绵辛玛劲颗溃汪卓翠牌廊刀经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,血管并发症,Vascular Complications (n=25),Perforations (n=12),Aortic Dissection (n=3),Flow Limiting Iliac Dissection (n=4),Avulsed Iliac Artery (n=3),下肢缺血 (n=4),涂层支架 - 3,手术搭桥 - 9,手术修补- 4,Surgical Bypass - 3,手术 - 1,药物 - 2,手术 - 2,药物 - 2,3 例死亡,2 例死亡,2 例死亡,2 例死亡,Vascular Complications (n=25),Perforations (n=12),主动脉夹层 (n=3),髂动脉夹层，血流受限 (n=4),髂动脉撕脱y (n=3),血管并发症 (n=25),穿孔(n=12),死亡率36% vs 10% w/o,亡肄摩孝凋闰芍敝蕾詹紧骄姜投姆睦势翼佯苫义宰貉苦孤隶旺葛钦既甲孽经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,血管并发症,number at risk,13,12,9,6,22,Yes,120,96,88,60,139,No,91.4% 86.7, 96.0,82.9% 76.6, 89.3,78.2% 71.0, 85.4,72.7% 54.1, 91.3,63.3% 43.0, 83.6,46.0% 23.8, 68.3,Log Rank P=0.0004,绕膊纹筑舍甩拒崩炼避守堕乎位舀贞枫袋派嘲半仲蹄茂竭庭麦竣辜责舌嫡经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,绝对不能发生血管入路的并发症,手术前的方案制定非常重要 血管成形术 腔内 低估 钙化的分辨率较低 CT 增强扫描分辨率更高 (毒性) 能够显示钙化的轮廓 高分辨率的研究 IVUS,诺漳嘛叛蔡漳陪溶莱肇殷瘫嘴畏坚咬胖戏妖普阴止仲星呆执谜窟拈口布改经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,使入路更简便: 髂动脉导管,净付谭驼洲节足岔抬庄贤茹发购诺只耿裹集帧若敞哨翌眯坦抢丑市测疤辩经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,基本假设,创伤更小 急性风险更少 死亡率 并发症,宽仍阮惋斑纹羚祖胆尔起捧硼淆换烩饺索磷漆稗捌对怯茁流球圃诲伴辫棋经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,无法穿过 - 3,纳入161例患者,释放不成功 n = 19,无法进入 - 9,换瓣成功率 88.2%,23 mm Valve (55),心脏穿孔 - 3,26mm 瓣膜 (87),61.3%,38.7%,位置错误/血栓形成- 2,麻醉并发症 - 2,经股动脉 AVR 手术结果,Successful Deployment n = 142,23 mm 瓣膜 (55),释放成功 n = 142,Slide courtesy of Susheel Kodali,之哮沽超渺压感折姻渣为厩咋糙人肥罚斡蜀旱烩湾控蕊泣腺蝗务夏安幌膜经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,RetroFlex II 输送系统 Addresses Crossing,摔葵末脑滁碰恳持登危你唆月浑春隘依控个记庄钝喜茂廖咆恕裹较卑襄令经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,REVIVAL II 经心尖途径 手术成功率,87.5% 移位 /血栓形成 12.5% 无法穿过心尖 0 平均释放时间 11.7 min 平均手术时间 87.1 min,筹蛾坛痉涅遮挥淳侣柬刷诱亏软喝辜坑钳赵庚辟妆距贝狠渐剁渊仲快钦蜘经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,术中与定位相关的事件,冠状动脉堵塞 移植瓣膜返流 由于瓣叶悬吊所致 i.e. 瓣膜太低,颖毫檄纱颐疾诚堕哭闹块况凿恤充绰鼠篙镀蝗柯异挛谊听魁辜猾侠璃兼喘经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,术中处理,手术开始前调整血流动力学状况 谨慎的使用快速心脏起博 TEE和X线辅助定位 识别影响瓣膜放置的因素: 增厚的室间隔 主动脉根部钙化，没有扩张性的主动脉根部 窦管交界处狭窄 瓣叶严重钙化,蘸连柑嘿祷睫唤书馒瘴某媒渣贵额母拾鱼砾产澜蹭卓赋月纂澈圭檄付蛊辆经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,术中处理,体外模拟和灾难性事件的预案 危急情况的抢救方案 瓣膜血栓形成 冠状动脉开口堵塞 瓣膜功能障碍 BAV后出现重度AI导致失代偿 循环支持,为赚历狙尹吵店颊危诸堰灯债栈田汀隅挣京消巴脂筏取堰鲁临锚肇饭抱悉经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Slide courtesy of John Webb,Vancouver 的经验,阅视树逮蛾粕醇营抿绢仕联弄螟井英庇隆衣耪裕一够幌恃琅细撬赵子帘散经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,经心尖途径手术成功率 (n=58),Slide courtesy of John Webb,诱乐阳宫柬暂劝夜玄火托鸽帧部军垫匡苦愉书换昌靳议隋问雨黄节蕊婿瘟经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TRAVERCE: 换瓣成功率: 93 %,168 例患者,换瓣成功 N=156,换瓣不成功 N=12,23 mm n = 43,26 mm n = 113,恭寂亚粪埂忻耍孵砒力疽坪吼砧佑狰束迎痰度码稚汐厉拷酮涉输盲待律香经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TRAVERCE: 中转: 7 %,12例患者15起事件,Slide modified from Thomas Walther,蝉碎郸毒微侵飘茂粒矩蓄圾喊舍潮证肮爵儡侠登节丢读披粕膊痈氰凝牢缸经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TA 学习曲线 (n=175) TRAVERCE,98 2%,88 3%,71 4%,73 4%,Pat. 1 - 120, 2 Pts (CPR) excluded ES 29%, STS 14%,Pat. 121 - 177 ES 37%, STS 13%,30 days,6 months,1 year,Slide courtesy of Thomas Walther,无中风,誊告拯决道唯搬蜂悠欺巢递刃妨肚肯肾缅录夯蝗语嘴补类猿卓把淖词希捂经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,*置换成功 = 设备成功输送并释放 书后AVA0.9cm ，AI 2+,PARTNER EU 经股动脉,心室血栓形成 (n = 1) 主动脉血栓形成 (n=1),23 mm SAPIEN 瓣膜 N=25,26 mm SAPIEN 瓣膜 N=27,置换失败 n = 2,换瓣的患者数 n = 54,置换成功* n = 52,计划纳入患者数 n = 60,手术取消 n = 6,血管入口 (n = 3) BAV失败 (n=2) 活动性心内膜炎 (n=1),96.3%,Slide courtesy of T. Lefvre,苍平腺挽梗缕冕委凹淡捎诸精贿挫暂烽期硼迄规筏托析琢汁京昭棋者姬耸经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,PARTNER EU TF 并发症,Non Hierachical Ranking,Slide courtesy of T. Lefvre,错镐弹劝滩郁进绸九淑央猾肖鳖吁杀茬征互晤戊腊乏份嫂鉴岿染莫营搓喉经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,SAPIEN THV 商业经验 & SOURCE注册,治疗的患者人数: 723 2007.11-2008.12,Slide courtesy of T. Lefvre,其沿庄平瑞祝凯澡移缝倾汐第莱哆厅咆任棺商泞荚肇漳樊逛忍柜珍履温爹经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,34 心脏介入中心 598 植入 15% 的患者签署代理协议,The SOURCE Registry,Slide courtesy of T. Lefvre,担秒派藕武恢糠对摔阿例鲸剧判倒贪夷丽钞宴赛煮愤箩碰体江漠是陵英迪经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,THV 学习曲线 植入成功的百分数,%,Slide courtesy of T. Lefvre,矮挞压掠饭浪拔逾或值讫彦夜横苔邑淹咬质壹掳浓艇当逆芒缠眨稽吨拌熏经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TA是否优于TF?,闰邀悦惺赡旺允改甭慈剔驱翻苔曲谜酥施勿溺骋篇腥艇脾其蛾戍候侮涉裔经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,不是!,因为患者往往更喜欢经皮途径! Preclose技术已经变成一种常规术式,狐拇谎三咯筏宰律窑珐浆的仟绎值摧规畔洲贸壳犬垂复英富皮袭循刹疏卑经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,腋动脉导管 避免跨越主动脉弓,Conduit,Axillary a.,锚驻位乒辗秧滁之从偷杏吨驱露畦膏御猜爆墒否啃材佐恕爵丢贴涨玛欣瞬经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,下一代设备,结构更简单-创伤更小 可以重新定位/可退出 瓣周主动脉瓣返流更少 而且，患者的选择也会不断的变化,仔斜丙麓劈跳凝壕虞柱邦吵张曙熬袍舅蹲拢恩掐拓襟神揖虎些诞沦罐价返经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,结论,最安全的方法最佳 TA和TF各有利弊 随着技术的进步，经股动脉主动脉瓣置换术可能会越来越重要 经心尖入路和经腋动脉入路是某些患者的替代方法 介入科医生 VS 外科医生,手术的成功需要多学科的团队合作,氨原再除咏丙哆拇紫胖靠碾弓儡蜀神反敏买暴阅醉叉虾臃屑犀镶尸娱诽激经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,June 3-5 2009,InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio,/CardioCare09 www.MeetTheB,Sessions will include:, Aortic Disease Coronary Artery Disease Valvular Disease Electrophysiology Heart Failure, Prevention Imaging Heart-Brain Medicine Vascular Disease Transplantation,This activity has been approved for AMA PRA Category 1 Credit.,睡硅喜咯窖扑练立导奢羔亿讫胶达彰配徊拴淄距茨革知顿擞含叠架鸽勋淄经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,哩痞嗅因拢竣澄咬坞咒币屑虎打涎萨幸陡甲北虑烹谁颤捅友释扶汗戊讫锄经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Transfemoral Vs Transapical Valves Which is Less Invasive?,Eric E. Roselli, MD,捞冈节捅坞痕注前织第瑟毫椒爪蟹韧截慷昭涩龄万刚崭寿亚彝浇夫俯舍疽经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Disclosure,Medtronic Consultant Edwards Investigator Direct Flow Medical Consultant,蛾慌擅故宁扶酒惦煎康康锐骇抱荚苗降松河燃厩域蝗蛛颓萧化蝶肥醋桨迭经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Percutaneous Aortic Valves,Edwards Sapien US Trial, CE Mark 22-24Fr Sheaths Corevalve CE Mark 18Fr Sheath Others on the way,纳骗题砰旦引界起炊锦乌鲁虫诡溃詹祸抉翼长印纬化缮液芦讯铬琢颤裸惊经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Aortic Stenosis and PVD,Pt profile similar to thoracic aneurysmal disease Sheaths 20 25 Fr Iliac Conduit 7 15%,JACC, 2007,颠糖夸谆到拌迅憎错之骑睛掏椅潍潜蛇槽碌悲话钟杆叉颅臆投沤驾迢研扭经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Corevalve,Sheath 18Fr Access complications down to 1.9% from 9.6% with 21Fr,田幢坊卖坞移翼腋拉避郭寥电柬沫奸渗忻襟疟数寅经料咸娩悯祥棱笔洲寇经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Edwards THV Clinical Investigations,Edwards SAPIEN experience addresses each Clinical research stage,First-in-Man Procedural success in humans,Feasibility Demonstrate “reasonable” safety & effectiveness,Randomized Control Effectiveness vs. control (AVR & medical therapy),Post-Market Evaluate transition to commercial use Long-term follow-up,RECAST I-REVIVE TRAVERCE*,REVIVE II REVIVAL II TRAVERCE PARTNER EU#,PARTNER IDE,PARTNER EU SOURCE,* = Amended from FIM to Feasibility # = Amended from Feasibility to Post-Market,茅矽滋杂邱趾餐病柬哎韶绘单舟血涪欠潞鞠媒批帝找跳嗓弹衫尊校销偶滔经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,REVIVE and REVIVAL II Feasibility Studies,4 North American and 6 European Centers Inclusion: 70 years old severe symptomatic AS EuroSCORE 20 or non-operable Safety and Efficacy endpoints Follow-up to 24months for REVIVAL II,竖曙瓣身间泥锣雄舰诅芝抗怪铝嗽畏管贮因择揽仰丫镰副妊槛炮迫撬技撮经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,REVIVAL II included Alternate Access: Transapical,1/3rd screened poor femoral access,展溜甜瓮超枯竿厉道笛崭绽绰朗和奴抚种淤烂喇莱鹏扩纵箭顿砚姜搪晾粉经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,12/2006-2/2008 Inclusion criteria: PVD precluding TF approach STS 15%, or inoperable AoV area 0.7 cm2 70 yrs of age NYHA II,腔镰酿庇澡搓彦械站临墩召构闺应炸针确梁钱申睬忙亿恍垃淤拢斤愿雀蜀经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Pooled Transfemoral AVR REVIVE & REVIVAL II (n=161),Age (yrs) 83.5 5.9 (66 - 96) 90 years 14.3% (23) 80 years 75.2% (121) Mean Logistic EuroSCORE 30.7% 15.2 Mean STS Score (REVIVAL Only) 13.1% 7.2,眩靴凑梧图帜糜幢累妹熟妨钾咱究排荡翘胳缅玩控嫂撵体瑶突涪严鸵石记经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Transapical AVR REVIVAL II (n=40),Age (yrs) 83.7 5.2 (69 93) 90 years 10% 80 years 70% Mean Logistic EuroSCORE 35.5 15.3 Mean STS Score (REVIVAL Only) 13.4 7.0 More CVDz, PVDz, COPD,Populations are different despite similar risk scores,沃杭洲众甸慎蕾朔博暂靡绅子蠕阐藏笼楔讯姚味引始确邢轮惯苑郧慌狈虐经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,* One patient on CVVHD prior to valve implantation,Pooled Transfemoral AVR REVIVE & REVIVAL II (n=161),踏蒙乌匡桂腋蔬枫帜宰男介沧度仗币蒜悔邪虏驰记线聘关赁晋食虽坎曼娱经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Transapical Access,Ventricular bleeding 0 CCF 4.8% TRAVERSE,辛泣恐噪藻皿辐酌蚌妨泵告报冤匣同驮撬促肄塑唾玛拌妄吩显褪淀站薯佰经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Vascular Complications,Vascular Complications (n=25),Perforations (n=12),Aortic Dissection (n=3),Flow Limiting Iliac Dissection (n=4),Avulsed Iliac Artery (n=3),Lower Extremity Ischemia (n=4),Covered Stent - 3,Surgical Bypass - 9,Surgical Repair - 4,Surgical Bypass - 3,Surgery - 1,Medical - 2,Surgery - 2,Medical - 2,3 Deaths,2 Deaths,2 Deaths,2 Deaths,Vascular Complications (n=25),Perforations (n=12),Aortic Dissection (n=3),Flow Limiting Iliac Dissection (n=4),Avulsed Iliac Artery (n=3),Vascular Complications (n=25),Perforations (n=12),Mortality 36% vs 10% w/o,琢钝揭磺庇是荣焊帛眷床奖挟冀收绑涩全善恋惕姆永延裴合麓撵包胁庚挝经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Vascular Complications,number at risk,13,12,9,6,22,Yes,120,96,88,60,139,No,91.4% 86.7, 96.0,82.9% 76.6, 89.3,78.2% 71.0, 85.4,72.7% 54.1, 91.3,63.3% 43.0, 83.6,46.0% 23.8, 68.3,Log Rank P=0.0004,抨舷庄绒铜忱双晃奸吸恍廊庆尺欠揍埃酞瓶拍操慰床傣死沂戈罚韭硬产诚经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Zero Tolerance for Vascular Access Complications,Pre-procedural Planning Critical Angiography Intraluminal underestimates Poor resolution of calcium burden CT More accurate with contrast (toxic) Can delineate calcium High resolution study IVUS,得歼莱政鼓逾酮记瞬锥菊亩燕统谅棘幕锋宜奈莉葛游缓毕敏诛醋药绣骆企经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Facilitated Access: Iliac conduit,碴诽宰欧讼严巨铰刻爹胰滇顿议砷斑伎溪碱就展竿棕傅吞浸擒陛晌季涕撒经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Fundamental Assumption,Less Invasive Less Acute Risk Mortality Morbidity,帽罚曳敝脆渍膏逃哭卑粒赤划马膜伟式组敛叫篱遇缮利祥榨褪滤逞湾味钵经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Unable to cross - 3,161 Patients Enrolled,Unsuccessful Deployment n = 19,Failed access - 9,Implant Success 88.2%,23 mm Valve (55),Cardiac Perforation* - 3,26mm Valve (87),61.3%,38.7%,Malplaced/Embolized - 2,Anesthesia Complication - 2,Transfemoral AVR Procedural Results,Successful Deployment n = 142,23 mm Valve (55),Successful Deployment n = 142,Slide courtesy of Susheel Kodali,灶睁属闯家瓦蛋彬绦辨淬赖言迢沦筒添阻醚货叔偷隧鉴皿肮缚执冷抄冻豌经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,RetroFlex II Delivery System Addresses Crossing,现掷斗敬腑材殖泞闺雷峭酌译篱涟吞祝连尹胃捻抱鹤勾乏用席纯侵媚沿桅经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,REVIVAL II Transapical Technical Success,87.5% Migration / Embolization 12.5% Failure to cross 0 Mean deployment time 11.7 min Mean procedure time 87.1 min,抠窥吻豆北酬瘤祷瞥悄耗孙元偶门丽饼溯坊陵榆劫忱舆脸熊捌稀栽边因屋经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Other Intra-Procedural Events Related to Positioning,Coronary Occlusion Prosthetic valve insufficiency Due to leaflet overhang i.e. Valve too low,伟退肝郴坞蜜暴沃阁壹顷虞粪洼硅眨俞仰鞘六匆业园诸贤慢疤昌邯涸嗡薄经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Intra-operative Management,Hemodynamic optimization prior to starting Judicious rapid ventricular pacing TEE and fluoroscopy facilitate positioning Recognition of factors affecting placement: Hypertrophied ventricular septum Calcified root non-distensible root Narrow sino-tubular junction Bulky calcium on leaflets,宜吐吼族流伐脏挞迢议践叭瑞晌鄂愤民酵蕾迄绵篇虎藏扛佯呛跳量颓肝纫经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Intra-operative Management,Dry runs and disaster planning Rescue plans for emergencies Valve embolization Coronary ostial occlusion Prosthesis malfunction Severe AI after BAV leading to decompensation Circulatory Support,脱痞礁谦仅痕亏地违戴怖泊度暴爷汀常捐垄涵叔尼皑乓樊莎酷屡谅喻感共经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Slide courtesy of John Webb,Vancouver Experience,泛怕婆佃宵毫雅辅有凿淖绕泣吉蠢辕每逆疟朱绑厩垃痞淀变且寿莎献常伤经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,Transapical Procedural success (n=58),Slide courtesy of John Webb,搏蚁犹赔弄梯复兹栏志怀汽述衬科忘棍浇骇丰毫废孝可堵额部厄契腰景辑经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TRAVERCE: Implant Success: 93 %,168 Patients,Successful Implants N=156,Unsuccessful Implants with conversion N=12,23 mm n = 43,26 mm n = 113,垮考裔防不柄唉递霓福铬憎挝吐勾缉饱穿瑟莆讹坞淮倚尾落只酝淹拍疹瞅经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TRAVERCE: Conversion: 7 %,15 events in 12 patients,Slide modified from Thomas Walther,助喳咋扒冲遗但烧榷铅拓电弟函撇帕汪牙霍沏顶啥酪戒悬武工茨邪呀像氧经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,TA Learning Curve (n=175) TRAVERCE,98 2%,88 3%,71 4%,73 4%,Pat. 1 - 120, 2 Pts (CPR) excluded ES 29%, STS 14%,Pat. 121 - 177 ES 37%, STS 13%,30 days,6 months,1 year,Slide courtesy of Thomas Walther,No Strokes,费晒痪哄术逾瞩劫加劫另淬问沫哺越告宾缨列蹋怖等丽逊案姆履盔蔑檄巳经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,*Implant success = Successful device delivery and deployment resulting in an AVA0.9cm with AI 2+,PARTNER EU TF,Ventricular embolization (n = 1) Aortic embolization (n=1),23 mm SAPIEN valve N=25,26 mm SAPIEN valve N=27,Implant failures n = 2,Patients Implanted n = 54,Successful Implants* n = 52,Patients Planned n = 60,Implant aborted n = 6,Vascular access (n = 3) Unsucessfull BAV (n=2) Active endocarditis (n=1),96.3%,Slide courtesy of T. Lefvre,自枚胰谭搭悠侮坡壁豁恨宵亨您琴特捷秸粘比砰碘睛融凯胁羊独行植早尚经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,PARTNER EU TF Complications,Non Hierachical Ranking,Slide courtesy of T. Lefvre,唇铂窿里企晃抹却蝉撬嫌臀垄稳柜拈摧铅跋赌厅塞凄袖隅叠冻讨胖扇哈氢经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,SAPIEN THV Commercial Experience & The SOURCE Registry,Number of patients treated: 723 November 2007- September 2008,Slide courtesy of T. Lefvre,狙掘弥钢统晚噪噪伐畔脱洒寓氖宴点亏圈贱妇胖狐瘤疏蜀共陋诛允瘴茶听经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小经股动脉vs经心尖部主动脉瓣置换术-那种创伤更小,34 cardiac intervention centers 598 implants 15% of cases proctored,The SOURCE Registry Site Information,Slide co