更多经皮瓣膜介入治疗循环支持.ppt

更多经皮瓣膜介入治疗: 循环支持,Eric E. Roselli, MD,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,瓣膜释放,未能送入- 3,纳入161名患者,释放失败 n = 19,送入失败 - 9,植入成功 88.2%,23 mm Valve (55),心脏穿孔* - 3,26mm 瓣膜 (87),61.3%,38.7%,移位/栓塞 - 2,麻醉并发症- 2,经股动脉 REVIVE and REVIVAL II 操作结果,Successful Deployment n = 142,23 mm 瓣膜 (55),成功释放 n = 142,Slide courtesy of Susheel Kodali,REVIVAL II 经心尖技术的成功性,87.5% 移位 / 栓塞 12.5% 送入失败 0 平均释放时间 11.7 min 平均操作时间 87.1 min,THV 学习曲线 成功植入百分比,%,Slide courtesy of T. Lefèvre,精确释放至关重要,REVIVE & REVIVAL II 腔内操作事件,因第一个瓣膜关闭不全导致瓣内瓣 1 (0.6%) 冠脉闭塞 2 (1.2%)* 瓣膜位置 不正确 1 (0.6%)* 瓣膜栓塞 1 (0.6%),* 瓣膜位置过低会导致重度主动脉返流和心脏停搏；心肺复苏时瓣膜移位至左心室 * 一例患者左主干植入支架，一例患者药物治疗,TRAVERCE: TA 可行性研究(n=168),Slide courtesy of T. Walther,TRAVERCE: 转复: 7 %,12名患者15个不良事件,Slide modified from Thomas Walther,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,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,完全心肺股股转流 ECMO Biomedicus 离心泵 Tandem 心脏,病历,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，循环支持的其他作用?,Corevalve 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 = Patients with Sapien in place and alive post-procedure (no conversion),The SOURCE Registry 30天结局-经股动脉,Slide courtesy T. LeFevre,REVIVE II & REVIVAL II 既往冠脉搭桥术后，FM生存曲线,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 合并二尖瓣关闭患者，KM生存曲线,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,部分高危患者，可以通过循环支持减轻左心室负荷,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 2009,InterContinental Hotel & Bank of America Conference Center Cleveland, Ohio,www.ccfcme.org/CardioCare09 www.MeetTheBuildings.com,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.,More Percutaneous Valves: Circulatory Support,Eric E. Roselli, MD,Disclosure,Medtronic Consultant Edwards Investigator Direct Flow Medical Consultant,Balloon Valvuloplasty,Rapid Ventricular Pacing,Valve Deployment,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 REVIVE and REVIVAL II Procedural Results,Successful Deployment n = 142,23 mm Valve (55),Successful Deployment n = 142,Slide courtesy of Susheel Kodali,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,THV Learning Curve Percent Successful Implant,%,Slide courtesy of T. Lefèvre,Accurate Deployment is Critical,REVIVE & REVIVAL II Intra-Procedural Events,Valve-in-valve due to incompetent valve 1 (0.6%) Coronary Occlusion 2 (1.2%)* Valve Malplacement 1 (0.6%)* Valve Embolization 1 (0.6%),* Valve placed too low resulting in severe AR and cardiac arrest; valve migrated into LV during CPR * One patient treated with left main stent, one patient managed medically,TRAVERCE: TA Feasibility study (n=168),Slide courtesy of T. Walther,TRAVERCE: Conversion: 7 %,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),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,www.ccfcme.org/CardioCare09 www.MeetTheBuildings.com,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.,