更多经皮瓣膜介入治疗循环支持

1、更多经皮瓣膜介入治更多经皮瓣膜介入治疗疗:循环支持循环支持声明声明Medtronic咨询机构Edwards 研发者Direct Flow Medical咨询机构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Slide courtesy of Susheel KodaliREVIVAL II 经心尖技术的成功性经心尖技术的成功性87.5%送入失败 0平均释放时间 11.7 min平均操作时间87.1 minTHV 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. Lefvrebaced精确释放至关重要精确释放至关重要TRAVERCE: TA 可

2、行性研究(n=168)植入成功率92.8 %30天存活率85 % 6个月 存活率70 %6个月未发生中风95 %6个月未发生心梗98 %不停跳77 %胸骨劈开 (转复)7.1% (n=12)Slide courtesy of T. WaltherTRAVERCE: 转复: 7 % 位置不正确位置不正确 低低 高高 422 瓣膜移位瓣膜移位 远端远端 心室心室321 主动脉关闭主动脉关闭 不全不全 中心性返流中心性返流 3+ 瓣环撕裂导致的瓣周漏瓣环撕裂导致的瓣周漏2+ 瓣周或中心性返流瓣周或中心性返流6222 升主动脉升主动脉夹层夹层1 二尖瓣腱索缠结二尖瓣腱索缠结112名患者15个不良事件S

3、lide modified from Thomas Walther教训教训 传统心脏手术中，二次手术不是死亡的独立预测因子抢救 经导管主动脉置换术中循环支持的作用是什么？ 抢救Roselli, et al. Adverse events during reoperative cardiac surgery: rescue JTCVS 08经导管主动脉置换术中抢救的适应症经导管主动脉置换术中抢救的适应症 血流动力学不稳定 累及冠脉 BAV后，重度主动脉瓣关闭不全 升主动脉或瓣环损伤循环支持的选择循环支持的选择 完全心肺股股转流 ECMO Biomedicus 离心泵 Tandem 心脏病历病历

4、83 岁老年女性 主动脉瓣狭窄并有严重临床症状 瓣膜面积0.6cm 重度 COPD, 脑血管意外病史， 肾动能不全, 肺动脉瓣功能障碍, 虚弱 行经股主动脉瓣置换 23mm 低血压难以纠正 超声心动图示左心扩张，重度左心室功能障碍经导管主动脉瓣置换术中，循环支经导管主动脉瓣置换术中，循环支持的其他作用持的其他作用?Corevalve 研究结果研究结果 91 - 97% 成功 压差 50 5mmHg 14% 2+ 主动脉关闭不全 患者植入瓣膜不匹配 9-25% 死亡率 15%（ Feasibility 研究） 9% （CE mark登记注册研究）*Population analyzed = Pa

5、tients with Sapien in place and alive post-procedure (no conversion)存活率存活率*93.6%NYHA Class INYHA Class IINYHA Class IIINYHA Class IV39.4%50.5%9.1%1.0%心肌梗塞心肌梗塞1.0%中风中风3.4%血管并发症血管并发症7.4%The SOURCE Registry30天结局-经股动脉Slide courtesy T. LeFevreREVIVE II & REVIVAL II既往冠脉搭桥术后，既往冠脉搭桥术后，FM生存曲线生存曲线93.0%88.

6、3, 97.784.6%77.8, 91.379.7%71.9, 87.678.3%66.3, 90.269.0%55.5, 82.659.5%45.0, 74.0numberat risk100786950114NO3229271646YESREVIVAL II合并二尖瓣关闭患者，合并二尖瓣关闭患者，KM生存曲线生存曲线97.2%91.8, 10085.8%74.2, 97.382.8%70.3, 95.383.3%66.1, 10077.8%58.6, 97.061.1%38.6, 83.6number at risk432812854部分高危患者，可以通过循环支持部分高危患者，可以通过循

7、环支持减轻左心室负荷减轻左心室负荷结论结论 非体外循环下经导管主动脉瓣置换技术操作上已经成功。 循环支持的主要作用是威胁生命并发症发生时的抢救措施。 经导管主动脉瓣置换术死亡的预测因子包括NYHA 分级,既往行冠脉搭桥术,和二尖瓣狭窄 2+ 高危患者可以行左房-股动脉部分分流 (TandemHeart)。June 3-5 2009InterContinental Hotel &Bank of America Conference Center Cleveland, O/CardioCare09www.MeetTheBSessions will incl

8、ude: Aortic Disease Coronary Artery Disease Valvular Disease Electrophysiology Heart Failure Prevention Imaging Heart-Brain Medicine Vascular Disease TransplantationThis activity has been approved for AMA PRA Category 1 Credit.More Percutaneous Valves:Circulatory SupportEric E. Roselli, MDDisclosure

9、MedtronicConsultantEdwards InvestigatorDirect Flow MedicalConsultantBalloon ValvuloplastyRapid Ventricular PacingValve DeploymentSlide courtesy of Susheel KodaliREVIVAL II TransapicalTechnical Success87.5%Failure to cross0Mean deployment time 11.7 minMean procedure time87.1 minTHV Learning Curve Per

10、cent Successful Implant%Slide courtesy of T. LefvrebacedAccurate Deployment is CriticalTRAVERCE: TA Feasibility study (n=168)Implant Success92.8 %30-day Survival85 % 6-month Survival70 %Freedom from Stroke 6 mo.95 %Freedom from MI 6 mo.98 %off-pump77 %Sternotomy (conversion)7.1% (n=12)Slide courtesy

11、 of T. WaltherTRAVERCE: Conversion: 7 % Malposition Low High 422 Valve migration Distal Ventricular321 Aortic Insufficiency Central regurgitation 3+ Paravavlular leak 2+ due to annular tear Paravalvular & central regurgitation6222 Ascending aorta dissection1 Mitral chordae entanglement115 events

12、 in 12 patientsSlide modified from Thomas WaltherLessons Learned Reoperation is not an independent predictor of mortality in conventional cardiac surgeryRESCUE What is the role of circulatory support in transcatheter AVR? RESCUERoselli, et al. Adverse events during reoperative cardiac surgery: rescu

13、e JTCVS 08Indications for Rescue in Transcatheter AVR Hemodynamic Instability Coronary impingement Severe AI after BAV Ascending aorta or annulus injuryCirculatory Support Options Full Cardiopulmonary Fem-fem bypass ECMO Biomedicus centrifugal pump Tandem heartCase 83 y/o female Severe symptomatic A

14、S 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 dysfunctionIs there another role for circulatory support during transcatheter AVR?Corevalve Results 91 - 97% technical success Gra

15、dients 50 5mmHg 14% 2+ AI PPM 9-25% Mortality 15% Feasibility trial9%CE mark Registry*Population analyzed = Patients with Sapien in place and alive post-procedure (no conversion)Survival*93.6%NYHA Class INYHA Class IINYHA Class IIINYHA Class IV39.4%50.5%9.1%1.0%MI1.0%Stroke3.4%Vascular Complications

16、 7.4%The SOURCE Registry30 Day Outcome-TFSlide courtesy T. LeFevreREVIVE II & REVIVAL IITF KM Survival if Prior CABG93.0%88.3, 97.784.6%77.8, 91.379.7%71.9, 87.678.3%66.3, 90.269.0%55.5, 82.659.5%45.0, 74.0numberat risk100786950114NO3229271646YESREVIVAL IITF KM Survival by Baseline MR97.2%91.8,

17、10085.8%74.2, 97.382.8%70.3, 95.383.3%66.1, 10077.8%58.6, 97.061.1%38.6, 83.6number at risk432812854In select high risk patients, there may benefit to unloading the LV with circulatory supportConclusions Transcatheter AVR has become a technically successful off-pump procedure Prime role for circulat

18、ory 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 patientsJune 3-5 2009InterContinental Hotel &Bank of America Conference Center Cleveland, O/CardioCare09www.MeetTheBSessions will include: Aortic Disease Coronary Artery Disease Valvular Disease Electrophysiology Heart Failure Pr