更多經(jīng)皮瓣膜介入治療循環(huán)支持

更多經(jīng)皮瓣膜介入治療:

循環(huán)支持EricE.Roselli,MD聲明Medtronic 咨詢機(jī)構(gòu)Edwards 研發(fā)者DirectFlowMedical 咨詢機(jī)構(gòu)快速心室起搏瓣膜釋放未能送入-3納入161名患者釋放失敗

n=19送入失敗-9植入成功88.2%23mmValve(55)心臟穿孔*-326mm瓣膜(87)61.3%38.7%移位/栓塞-2麻醉并發(fā)癥-2經(jīng)股動(dòng)脈REVIVEandREVIVALII操作結(jié)果SuccessfulDeployment

n=14223mm

瓣膜(55)成功釋放

n=142SlidecourtesyofSusheelKodali

87.5%移位/栓塞 12.5%送入失敗 0平均釋放時(shí)間 11.7min平均操作時(shí)間 87.1minTHV學(xué)習(xí)曲線

成功植入百分比%SlidecourtesyofT.Lefèvrebaced精確釋放至關(guān)重要REVIVE&REVIVALII

腔內(nèi)操作事件因第一個(gè)瓣膜關(guān)閉不全導(dǎo)致瓣內(nèi)瓣–1(0.6%)冠脈閉塞–2(1.2%)**瓣膜位置

不正確–1(0.6%)*瓣膜栓塞–1(0.6%)* 瓣膜位置過(guò)低會(huì)導(dǎo)致重度主動(dòng)脈返流和心臟停搏；心肺復(fù)蘇時(shí)瓣膜移位至左心室** 一例患者左主干植入支架，一例患者藥物治療TRAVERCE:

TA可行性研究(n=168)植入成功率92.8%30天存活率85%6個(gè)月

存活率70%6個(gè)月未發(fā)生中風(fēng)95%6個(gè)月未發(fā)生心梗98%不停跳77%胸骨劈開(kāi)

(轉(zhuǎn)復(fù))7.1%(n=12)SlidecourtesyofT.WaltherTRAVERCE:

轉(zhuǎn)復(fù):7%

位置不正確

低

高

422

瓣膜移位

遠(yuǎn)端

心室321

主動(dòng)脈關(guān)閉不全

中心性返流>3+

瓣環(huán)撕裂導(dǎo)致的瓣周漏>2+

瓣周或中心性返流6222

升主動(dòng)脈夾層1

二尖瓣腱索纏結(jié)112名患者15個(gè)不良事件SlidemodifiedfromThomasWalther教訓(xùn)Roselli,etal.Adverseeventsduringreoperativecardiacsurgery:rescueJTCVS08血流動(dòng)力學(xué)不穩(wěn)定累及冠脈BAV后，重度主動(dòng)脈瓣關(guān)閉不全

升主動(dòng)脈或瓣環(huán)損傷循環(huán)支持的選擇完全心肺股股轉(zhuǎn)流ECMOBiomedicus離心泵Tandem心臟病歷83歲老年女性主動(dòng)脈瓣狹窄并有嚴(yán)重臨床癥狀瓣膜面積0.6cm重度COPD,腦血管意外病史，

腎動(dòng)能不全,肺動(dòng)脈瓣功能障礙,虛弱行經(jīng)股主動(dòng)脈瓣置換23mm低血壓難以糾正超聲心動(dòng)圖示左心擴(kuò)張，重度左心室功能障礙Corevalve研究結(jié)果91-97%成功壓差~505mmHg14%2+主動(dòng)脈關(guān)閉不全患者－植入瓣膜不匹配9-25%死亡率15%（Feasibility研究）9%（CEmark登記注冊(cè)研究）*Populationanalyzed=PatientswithSapieninplaceandalivepost-procedure(noconversion)存活率*93.6%NYHAClassINYHAClassIINYHAClassIIINYHAClassIV39.4%50.5%9.1%1.0%心肌梗塞1.0%中風(fēng)3.4%血管并發(fā)癥7.4%TheSOURCERegistry

30天結(jié)局-經(jīng)股動(dòng)脈SlidecourtesyT.LeFevre0.10.20.30.40.50.60.70.80.9136912MonthspastProcedureFreedomfromDeath00NoYesLogRankP=0.00893.0%[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]numberatrisk100786950114NO3229271646YESREVIVALII

合并二尖瓣關(guān)閉患者，KM生存曲線FreedomfromDeathMonthspastProcedureLogRankP=0.047997.2%[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]numberatrisk432812854部分高?；颊撸梢酝ㄟ^(guò)循環(huán)支持減輕左心室負(fù)荷結(jié)論June3-52009InterContinentalHotel&

BankofAmericaConferenceCenterCleveland,OhioSessionswillinclude:?AorticDisease?CoronaryArteryDisease?ValvularDisease?Electrophysiology?HeartFailure?Prevention?Imaging?Heart-BrainMedicine?VascularDisease?TransplantationThisactivityhasbeenapprovedforAMAPRACategory1Credit.?MorePercutaneousValves:

CirculatorySupportEricE.Roselli,MDDisclosureMedtronic ConsultantEdwards InvestigatorDirectFlowMedical ConsultantBalloonValvuloplastyRapidVentricularPacingValveDeploymentUnabletocross-3161PatientsEnrolledUnsuccessfulDeployment

n=19Failedaccess-9ImplantSuccess88.2%23mmValve(55)CardiacPerforation*-326mmValve(87)61.3%38.7%Malplaced/Embolized-2AnesthesiaComplication-2TransfemoralREVIVEandREVIVALIIProceduralResultsSuccessfulDeployment

n=14223mmValve(55)SuccessfulDeployment

n=142SlidecourtesyofSusheelKodaliREVIVALIITransapical

TechnicalSuccess

87.5%Migration/Embolization 12.5%Failuretocross 0Meandeploymenttime 11.7minMeanproceduretime 87.1minTHVLearningCurve

PercentSuccessfulImplant%SlidecourtesyofT.LefèvrebacedAccurateDeploymentisCriticalREVIVE&REVIVALII

Intra-ProceduralEventsValve-in-valveduetoincompetent

valve–1(0.6%)CoronaryOcclusion–2(1.2%)**ValveMalplacement–1(0.6%)*ValveEmbolization–1(0.6%)* ValveplacedtoolowresultinginsevereARandcardiacarrest;valve

migratedintoLVduringCPR** Onepatienttreatedwithleftmainstent,onepatientmanagedmedicallyTRAVERCE:

TAFeasibilitystudy(n=168)ImplantSuccess92.8%30-daySurvival85%6-monthSurvival70%FreedomfromStroke@6mo.95%FreedomfromMI@6mo.98%off-pump77%Sternotomy(conversion)7.1%(n=12)SlidecourtesyofT.WaltherTRAVERCE:

Conversion:7%

Malposition

LowHigh

422

Valve

migration

Distal

Ventricular321

Aortic

InsufficiencyCentralregurgitation

>3+

Paravavlular

leak

>2+duetoannular

tear

Paravalvular¢ral

regurgitation6222

Ascending

aorta

dissection1

Mitral

chordae

entanglement115eventsin12patientsSlidemodifiedfromThomasWaltherLessonsLearnedReoperationisnotanindependentpredictorofmortalityinconventionalcardiacsurgery RESCUEWhatistheroleofcirculatorysupportintranscatheterAVR?

RESCUERoselli,etal.Adverseeventsduringreoperativecardiacsurgery:rescueJTCVS08IndicationsforRescueinTranscatheterAVRHemodynamicInstabilityCoronaryimpingementSevereAIafterBAVAscendingaortaorannulusinjuryCirculatorySupportOptionsFullCardiopulmonaryFem-fembypassECMOBiomedicuscentrifugalpumpTandemheartCase83y/ofemaleSeveresymptomaticASValvearea0.6cmSevereCOPD,h/oCVA,renalinsufficiency,PVD,frailUnderwenttransfemoralAVR–23mmHypotensiondidnotrecoverEchoshoweddilatationandsevereLVdysfunctionIsthereanotherroleforcirculatorysupportduringtranscatheterAVR?CorevalveResults91-97%technicalsuccessGradients~505mmHg14%2+AIPPM9-25%Mortality15%Feasibilitytrial 9% CEmarkRegistry*Populationanalyzed=PatientswithSapieninplaceandalivepost-procedure(noconversion)Survival*93.6%NYHAClassINYHAClassIINYHAClassIIINYHAClassIV39.4%50.5%9.1%1.0%MI1.0%Stroke3.4%VascularComplications7.4%TheSOURCERegistry

30DayOutcome-TFSlidecourtesyT.LeFevreREVIVEII&REVIVALII

TFKMSurvivalifPriorCABG0.10.20.30.40.50.60.70.80.9136912MonthspastProcedureFreedomfromDeath00NoYesLogRankP=0.00893.0%[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]numberatrisk100786950114NO3229271646YESREVIVALII

TFKMSurvivalbyBaselineMRFreedomfromDeathMonthspastProcedureLogRankP=0.047997.2%[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]numberatrisk432812854Inselecthighriskpatients,theremaybenefittounloadingth