NOVEDADESQUIRÚRGICAS EN TERAPIA VALVULAR. 2011
José L. Pomar, MD, PhDDirector AdjuntoInstituto Clínico del TóraxHospital ClinicUniversidad de Barcelona
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
PRIMERAS PRÓTESIS HETEROTÓPICAS
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
PRIMERAS PRÓTESIS ORTOTÓPICAS
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
ULTIMOS DISEÑOS DE BIOPROTESIS
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
LO MAS NOVEDOSO, ES NOVEDOSO ?
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
VALVULA AÓRTICAHomoinjertos: Presente y futuro de unos pocos privilegiadosBioprótesis: Crecimiento exponencial. Nuevos diseños. Nuevos accesos
Procedimientos percutaneos.Prótesis mecánicas: la anticoagulación, será imprescindible?
VALVULA MITRALReparar siempre mejor que cambiar?Algo nuevo en la reparación?Procedimientos percutaneos
VALVULA TRICUSPIDEReparaciones en VD muy dilatadosPrótesis: Está ya todo dicho?
LA IMAGEN Y LA CIRUGIA VALVULAR
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
VÁLVULA AÓRTICA
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
HOMOINJERTOS E INGENIERIA TISULAR
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
HOMOINJERTOS Y SOLUCIONES
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
REPARACION VALVULAR AÓRTICA
Form follows function
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
BIOPROTÉSIS
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
BIOPROTÉSISDel implante tradicional al simplificado
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
BIOPROTÉSISDel implante tradicional al simplificado
Perceval de SorinIntuitive de Edwards
Hospital ClinicUniversity of Barcelona
CURSO PRACTICO DE ACTUALIZACIÓN CARDIOVASCULAR. Barcelona 2008
90%
69%P=0.01
179 patients with symptomatic severe aortic stenosis
Porcelain ascending aorta
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
2 parts composite graft
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
INDICATIONS for TAVI
•Quantitative assessment
•LOGISTIC EUROSCORE >20%
•STS >10%
•Clinical judgment
•Chest radiation
•Previous CABG
•Porcelain aorta
•Liver cirrhosis
•Etc…..
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
≤ 30-Day Adverse Events (N = 948)
30‐Day All Mortality Rate 68 (7.2%)Cardiac Deaths** 42 (4.4%)Myocardial Infarction 6 (0.6%)Major Arrhythmias 30 (3.2%)Pacemaker 84 (8.9%)Renal Failure 10 (1.1%)Stroke 14 (1.5%)TIA 5 (0.5%)Structural Valve Dysfunction 0 (0.0%)Valve Migration 0 (0.0%)
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Interferencia con los orificios coronarios
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Pseudoaneurisma post apical
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Symetis reports on its trans-apical ACURATE TATM first-in- man clinical study
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Paniagua Enable PHV AorTx
SadraDirect Flow
Heart Leaflet Technologies Perceval JenaValvexchange
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Unknowns by 2011
• Unknown durability in humans after 6 years
• Unknown effects on heart failure progression
• Unknown effects of remaining AoI on ventricular remodeling
• Unknown effect on the ability to do subsequent valve repair or replacement
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
MCRI's On-X Prosthetic Heart Valve in Aspirin Study; Clinical Study May Provide Evidence to Support Eliminating the Use of Warfarin As an Anticoagulant for On-X Mechanical Valve Recipients
PROACT: Early results show high-risk patients do well with low warfarin and carbon valve
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Enrollment Objective Achieved for Aspirin and Clopidogrel Patient Group of the On-X Heart Valve Anticoagulation Clinical Study
Two Antiplatelets No Better Than Aspirin Alone After TAVI
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
VÁLVULA MITRAL
The echocardiographic assessment
Perforation of the leaflet observed under normal, colour doppler and at surgery
The Master of Valve therapy Bad Neustadt, October 2011
Large defect on the Anterior Leaflet
The Master of Valve therapy Bad Neustadt, October 2011
Flail leaflet after chordal rupture in BE
Perforation on a previously rheumatic mitral
The Master of Valve therapy Bad Neustadt, October 2011
The Master of Valve therapy Bad Neustadt, October 2011
Repairing with a pericardial patch a Type I lesion of an acute endocarditis
RD.Leiden MCRD.Leiden MC
The Master of Valve therapy Bad Neustadt, October 2011
Reconstruction of anterior leaflet and posterior commissure
The Master of Valve therapy Bad Neustadt, October 2011
The Master of Valve therapy Bad Neustadt, October 2011
SURGICAL FINDINGS SURGICAL REPAIR
The use of a prosthetic ring was unnecessary in this case
The Master of Valve therapy Bad Neustadt, October 2011
Posterior annulus managementradical excisiondirect reconstruction ?autologous pericardial patch with GApartial homograft
Anterior annulus managementmitro-aortic continuity mitro-aortic managementradical excisionmulti-patch reconstruction
Commissuresradical excisionplication and annuloplastypartial homograft
Mitral abscesses and tissue destruction management
The Master of Valve therapy Bad Neustadt, October 2011
Mitral homograft implant in an IVDA patient and histopathology after 12 years
Mitral homograft
Partial Homograft Mitral Valve Implantation
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Indirect MITRAL VALVE AnnuloplastyCS - Reshaping
Distal AnchorProximal Anchor
Bridge
Distal AnchorProximal Anchor
Bridge
Carillon XE
PTMA ImplantHub and Cap (Ti)
PTMA Implant DeviceProximal Stops (Ti)
PTMA Implant DeviceShaft ( NiTi )
PTFE UnusedLumen Filler
PTMA ImplantHub and Cap (Ti)
PTMA Implant DeviceProximal Stops (Ti)
PTMA Implant DeviceShaft ( NiTi )
PTFE UnusedLumen Filler
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
MONARCH ELS
CARRILLON CARDIAC DIMENSIONS
PTMA VIACOR
Indirect MITRAL VALVE AnnuloplastyCS – Reshaping
NIH CERCLAGE of Lederman
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
• Circumferential tension around mitral annulus• CS – proximal septal branch of GCV –
image guided (MRI roadmapping coupled with fluoroscopy) traversal of myocardium to reenter right heart chambers
• Circle is closed by snare retrieval than applying and fixing graded tension to reduce MR
• Successful MR reduction in 14/16 swine with suitable anatomy
Direct Annuloplasty
• Retrograde access to post MV annulus - Direct annular reduction: Suture-anchor plication
• Guiding catheter in CS with radio-opaque markers placed at P1, P2 and P3
• Trident catheter delivers wires in P1, P2 and P3• FIM: Jan-2008 – Dr. Adrian Ebner – Paraguay• CE Pilot study PI: Prof. E. Grube
MITRALIGN
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
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Direct Annuloplasty
Cinching implant below the posterior mitral annulus -Trigone-to-Trigone
AnchorsAnchors Therapeutic Area
Therapeutic Area
Anterior LeafletAnterior Leaflet
Posterior Leaflet
Posterior Leaflet
P1P1
P2P2
P3P3
Aortic ValveAortic Valve
AnchorsAnchors
ACCUCINCH GDS
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
• Ring implanted surgically during conventional surgical repair
• Direct mechanical adjustability• in OR or Cath Lab• 2 sizes• 24 to 30• 30 to 38
Direct Adjustable Annuloplasty(Hybrid Techniques)
Pre-implant Post-implant Post-adjustment
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
MICARDIA
• Ring implanted surgically during conventional surgical repair
• RF energy mediated reshaping• In OR by suture-electrodes• In Cath Lab with a catheter-
basket and electrode mounted on the splines - docking confirmed by impedance
• Completed FIM trials 2012
• Ring implanted surgically during conventional surgical repair
• RF energy mediated reshaping• In OR by suture-electrodes• In Cath Lab with a catheter-
basket and electrode mounted on the splines - docking confirmed by impedance
• Completed FIM trials 2012
Direct Adjustable Annuloplasty(Hybrid Techniques)
DYNAPLASTY MICARDIA
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
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Leaflet Plication
• Over 300 cases - Everest I and Everest II (randomized+registry) in 36 sites• Freedom from death at 36 Mo: 97%• Freedom from Sx at 36 Mo: 85%• Freedom from death, surgery or MR>2+ at 36 Mo: 67%
• Guide catheter 17-19 Fr
• Stitch Catheter 11-12 Fr
• Housing with a vacuum port, needles and suture
• Fastener catheter 7 Fr.
• After FIM, device is being redesigned
• Guide catheter 17-19 Fr
• Stitch Catheter 11-12 Fr
• Housing with a vacuum port, needles and suture
• Fastener catheter 7 Fr.
• After FIM, device is being redesigned
Stitch + Nitinol AnchorStitch + Nitinol Anchor
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
MITRACLIP ABBOT
Leaflet PlicationMitraFlex – TransCardiac Therapeutics
TransCardiac Port™• Allow access into the chambers of a beating
heart
TransCardiac Navigator™• Enables maneuverability within a beating heart
Clip advanced to hold the leaflets at midpoint
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Leaflet Plication
Leaflet Stabilizer ™ deployed to hold leaflets in place
Reach the Mitral ValvePercutaneously
Clip or Stitch to hold the leaflets at midpoint
MitraFlex – TransCardiac Therapeutics
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Percutaneous Artificial Chordae Implantation
Fiber optics
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
NEO CHORDS
Percutaneous Artificial Chordae Implantation
Artificial Cordae ImplantedArtificial Cordae Implanted
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
BABIC DEVICE
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
MitraClip
Space Occupier
• Femoral Access• I.C.E visualization• Trans-septal approach• Anchor in apex• Mitra-Spacer™ positioned mid-valve• Self-centering• Currently finishing chronic animal
studies – Pre Clinical• Acute animal n=40• Chronic animal n=10 (30,90 and 180 days)
Mitra-Spacer and Percu-Pro by Cardiosolutions
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
• Active anchoring• Rigidity and structure is
not stent based• Re-deployable• Fully valve-sparing• In-vivo ovine testing is
ongoing
Endovalve-Herrmann Prosthesis
Percutaneous Mitral Valve Implantation
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Percutaneous Mitral Valve ImplantationGeorg Lutter Mitral Valve Prosthesis
Figure 1. Transesophageal echocardiographic views of the mitral valved stent. Figure 1A shows the valved stent along LV long axis view at 0 degree angle. Note the visible valve leaflets inside the body of the stent. Figure 1B represents the color frame showing the unobstructed LVOT and its relationship with the new mitral valved stent.
Figure 2. TEE Doppler examination of the mitral valved stent and LVOT flows. Figure 2A illustrates the amount of regurgitation (trace) on Continuous Wave Doppler exam to assess the forward flow through the mitral valved stent. Figure 2B shows the Pulse Doppler exam through the LVOT showing unobstructed flow by the neighboring mitral valved stent.
(Lozonschi L and Lutter G: University of Kiel and University of Wisconsin)
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Minithoracotomy
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
VÁLVULA TRICUSPIDE
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
VÁLVULA TRICUSPIDE
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
Callahan et al.Am Heart J.1982;50:762
Is it to repair, replace by a bioprosthesis or a mechanical device?
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO
CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011
LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO
Allied Health Care Professionals The Roland Hetzer Society, Lisbon 2011
But training and caring of all our allied personnel is also crucial
Allied Health Care Professionals The Roland Hetzer Society, Lisbon 2011
Christakis NA, Fowler JH. NEJM 357 (4):370‐379, 2007
The obesity network
Allied Health Care Professionals The Roland Hetzer Society, Lisbon 2011
Hubs in biological interaction networksExperimental asthma in a mouse model
Allied Health Care Professionals The Roland Hetzer Society, Lisbon 2011
SystemsCollection of linked individual elements with emerging properties that can not be attributed to each element considered separately.