Trans-catheter Aortic Valve

Implantation

Should we all be doing this?

Dr Philip MacCarthy BSc PhD FRCP

Consultant Cardiologist

King’s College Hospital, London, UK.

BCIS Autumn Meeting, Crewe Hall, Crewe, September 26th 2008

Otto et al N Engl J Med 1999;341:142–7

Is there an unmet need?

(SCTS 5th Blue Book 2003)

AVR has become more common in the

elderly

Is there an unmet need?

What do we currently have to

offer?

Trans-catheter aortic valve

implantation

CoreValve ‘Revalving’ system – trans-femoral

Edwards Sapien™ prosthesis

Trans-femoral (using the ‘RetroFlex’ catheter)

Trans-apical (using the ‘Ascendra’ catheter)

CoreValve ‘ ReValving’ System

Edwards Sapien™ Trancatheter

Heart Valve prosthesis

What are the challenges of setting

up a TAVI programme in the real

world?

King’s College Hospital Experience

35 patients treated with the Edwards device

17 Trans-femoral

18 Trans-apical

First 17 of these as part of the PARTNER-

EU study,

Next 18 in the SOURCE registry

King’s College Hospital Experience

20 women (57%)

Mean age - 83.9yrs

Mean Log Euroscore - 20.3 (porcelain aorta)

Mean peak AV gradient - 85.8mmHg

Mean AVA - 0.61cm2

Median LOS - 8 days

In-hospital mortality - 2 (5.7%)

Patient work-up

Lung/renal function tests

Carotid Dopplers

CT aorta – without contrast

Trans-thoracic echo Morphology of AV – peak/mean grad + AVA

Dimensions of AV annulus

Morphology of septum

Presence/mechanism of MR

LV systolic function

PAP if possible

TOE – if annulus 24mm or greater

Patient work-up

Cardiac Catheterisation

Coronary angiogram

RH cath with PAP

Aortogram (PA or LAO) – 30ml @ 15ml/sec

Iliofemoral angiogram – 30ml @ 6ml/sec

No angioseal!

The Team

Dedicated Anaesthetist(s)

Echocardiologist

Perfusionist

Surgical scrub nurse

Cath lab scrub nurse

Surgeon(s)

Interventional Cardiologist(s)

The Company (for valve crimping)

Fluoro

Cardio

CT Surg

Cath lab kit

Valve crimping

Surgical

kit

Echo

Machine

Echo

CP bypass

Anaes.

Machine

Anaes

Nurse

Nurse

Rad

Tech

ODA

Rep

The Learning Curve

Trans-femoral pAVR

TF Valve deployment

Trans-apical pAVR

A higher risk patient group

TA valve deployment

The importance of peri-

procedural imaging

Stenosed native aortic valve

Guidewire across native AV

Valve deployment

Edwards Sapien valve in-situ

Potential peri-procedural

complications Vascular access

Passage of introducer sheath

Surgical repair

Iliac dissection/rupture

Balloon valvuloplasty Aortic regurgitation

CHB on background of RBBB

Valve deployment Occlusion of coronary ostia

Displacement of prosthesis

Rapid pacing

Other – Interference with the mitral valve

CVA

Failed femoral access

Iliac balloon occlusion

Occlusive iliac dissection

Iliac artery rupture…

…repaired with a covered stent

The importance of case selection

Patients with advanced pulmonary disease may do better with a TF approach

Poor LV systolic function - less room for error

The aetiology of depressed LV function and MR

Beware RBBB

So should we all be doing it?

Some words of caution

The precise need is unknown

There is currently no long-term data

Funding issues remain a problem

So should we all be doing it?

At the moment NO - because:

Experience should be concentrated in major centres

New centres should be closely proctored

Centre must have:-

Experienced cardiac anaesthetists

Cardiopulmonary bypass facility

Excellent imaging ability

Dedicated cardiac ITU/recovery area

Long-term data/a solution to funding is needed

Acknowledgements

King’s TAVI Team:-

CT Surgeons - Olaf Wendler &

Ahmed El-Gamel

Cardiologists – Phil MacCarthy &

Martyn Thomas

Echocardiologist – Mark

Monaghan

Anaesthetists – Emma Alcock &

Kailasam Rajagopal

Research Sister/Co-ordinator –

Karen Wilson/Beth Brickham

Other cath lab/theatre staff involved