Download POST AORTIC VALVE REPLACEMENT

Diksha Wadhwa, Final Year
Gillian Lieberman, MD
10/24/2011-11/20/2011
Unusual Course of Elderly Patient with
Severe Aortic Stenosis
DIKSHA WADHWA
SRM UNIVERSITY, INDIA
Gillian Lieberman, MD
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
3 HOPI
3 PROBLEM LIST
3 REPORTS OF 2009
3 PLAN
3 PHYSICAL EXAMINATION
3 PRE-OP REPORTS
3 OPERATIVE PROCEDURE
3 REEXPLORATORY SURGERY
3 DISCUSSION
3 PERCUTANEOUS MEDICORE AORTIC VALVE
REPLACEMENT TRIAL
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
HOPI
83 year old female with a past history of CABGx3 in 2000 who
began to experience chest pain again in 2009 and worsening
shortness of breath.
NYHA Class II
On investigating
Troponin peaked at 0.43(0-0.1 ng/ml) and an echo revealed
severe aortic stenosis.
CT scan then revealed an extensively calcified aorta.
Cardiac catheterization revealed severe native and graft disease.
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
PROBLEM LIST
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CAD
NSTEMI
AS with AVA 0.61 cm (<0.8cm2)
Calcified aorta
Hypertension
Dyslipidemia
MI in 1971, 2000 and 2009
Hypothyroidism
Paroxysmal Atrial Fibrillation
Osteoarthritis
Abdominal aortic aneurysm
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Calcified aorta
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Calcified
aorta
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Abdominal aortic
aneurysm
(96mm
* 41.9mm)
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
CT CHEST W/O CONTRAST 2009
Abdominal
aneurysm
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
11/2009
Calcified aorta
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Physical Examination
y Pulse: 54
y B/P: 160/80
y Neck: Neck supple, trachea midline, carotid upstroke.
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Bilateral bruit vs. radiating murmer.
Chest: Well healed surgical sternotomy.
Heart: Murmer RSB radiating throughout.
Extremities: trace RLE pedal edema.
Pulses: palpable peripheral pulses.
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Treatment Options
y Standard aortic valve replacement
y Given calcified aorta, not a surgical candidate
y Percutaneous core valve placement
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
PRE OP CHEST XRAY
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Preliminary cath report:
y SVG-OM and PDA: known occluded.
y Infrarenal aneurysm
y 80% RCI ostial stenosis
y LCIA occluded at origin with collaterals to distal vessel
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Operative Steps for Percutaneous Approach
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Left Subclavian Artery Cutdown
Left Heart Catheterization
Hemi-sternotomy
Catheter Placement,
Left Subclavian Artery Catheter Placement,
Ascending Aorta Temporary Pacemaker Placment,
Right IJ vein Temporary Pacemaker Placement,
Left Femoral Vein Aortography,
Ascending Aorta Balloon Aortic Valvuloplasty
Percutaneous Aortic Valve Replacement
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Subclavian Approach
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Medicore valve in place
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
POST OP CHEST XRAY
Termination
of ETT 5cm
above carina
Pulmonary
congestion
2 chest
tubes
placed
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
POST CHEST TUBE REMOVAL
Right base
opacity
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
POD-2
Homogenous
opacities in the
major fissure
and right lung
base
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
C/O:`PATIENT 3 DAYS PO COMPLAINS OF CHEST
PAIN
INVESTIGATION: SUDDEN DROP IN HAEMATOCRIT
FROM 34.2% TO 28.5%
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
CT THORAX
RIGHT
SIDED
PLEURAL
EFFUSION
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
CT SCAN CHEST
LUNG
COMPRESSION
HAEMOTHORAX
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Extravasation from RIMA
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
RE-SURGERY
PROCEDURES: Mediastinal re-exploration and repair of
bleeding right internal mammary artery and vein.
OPERATIVE FINDINGS: There was a copious amount of
clotted blood in the right hemithorax as well as non clotted
blood. There was bright red blood emanating from
transected mammary.
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
CHEST XRAY POST EVACUATION
ETT IN
PLACE
MARKED
IMPROVEMENT
IN RGT
HAEMOTHORAX
LEFT LUNG
BASAL
ATELECTASIS
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
POD -4
SMALL APICAL
PNEUMOTHORAX
SMALL
RETROCARDIAC
PLEURAL
EFFUSION
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
POD-6
SMALL
PLEURAL
EFFUSION
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
POD-6 LATERAL VIEW
PROSTHETIC
CORE
VALVE IN
PLACE
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
ECHO Post Op
y Mild symmetric left ventricular hypertrophy with preserved
global and regional function.
y Well-seated Corevalve prosthesis with normal gradient and
no regurgitation.
y Mild to moderate pulmonary hypertension.
y The severity of mitral regurgitation is reduced (but not well
seen on current study)
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
PATIENT WAS ASYMPTOMATIC AND
DISCHARGED ON POD-7
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
PERCUTANEOUS MEDICORE AORTIC
VALVE REPLACEMENT TRIAL
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Statistics of heart valve replacement
surgery
It is estimated that more than 60,000 patients per year are
undergoing heart valve replacement in the United States.
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Complications of valve
replacement surgery
y primary valve failure
y prosthetic valve endocarditis (PVE)
y prosthetic valve thrombosis (PVT)
y thromboembolism
y mechanical hemolytic anemia
y Anticoagulant related haemorrhage
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Starr-Edwards Silastic ball valve
Medtronic hall tilting disc valve
St jude mechanical heart
valve
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Source: images from medscape
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Hancock MII Aortic valve
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Source: images from medscape
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Bioprosthetic valves
y A bioprosthetic valve is a replacement valve, usually for the
heart, made of either human or animal tissue.
Bioprosthetic valves
Autograft
Homografts
Xenograft
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Mechanical Valves
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Advantages
Disadvantages
y Durability
y Life long use of
y Less risk of re-surgery
anticoagulants
y Loud and noisy
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Bioprosthetic valves
Advantages
Disadvantages
y No use of life long
y Less durability
anticoagulating therapy.
y Valves do not click.
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Pig valves (10-15 yrs)
y Cow valves(20 yrs)
y
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CoreValve bioprosthesis: A – side view; B – aortic outflow view; C – partially “compressed” prior
to mounting on the delivery CoreValve bioprosthesis: A – side view; B – aortic outflow view; C –
partially “compressed” prior to mounting on the delivery
device; D – completely mounted on the delivery system.
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Medtronic heart valve
y The Medtronic Mosaic® bioprosthetic heart valve
(bioprosthesis), carefully crafted from porcine tissue and
preserved with innovative techniques, is an artificial heart
valve.
y The Medtronic Mosaic bioprosthesis is a third-generation
valve made of porcine (pig) tissue. The tissue is attached to a
cloth-covered, flexible plastic frame, called a stent. The
bioprosthesis is then sewn into place where the patient’s
diseased valve used to be.
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Percutaneous Approach
The subclavian approach was found to be feasible and safe with
procedural success and in-hospital complication rates similar to
those of femoral approach.
y The subclavian approach presents a safe and feasible access route
for TAVI in patients without suitable femoral access.
y Use of subclavian access has increased from 0% in 2007 to 18% in
2010
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Clinical Experience :CoreValve Transcatheter Aortic Valve
Implantation received CE-Mark approval for the treatment of
severe Aortic Stenosis in 2007. To date, over 12,000 patients in
34 countries have undergone the CoreValve procedure.
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Complications of Cardiopulmonary Open
Heart Surgery
y Postperfusion syndrome
y Haemolysis
y Capillary leak syndrome
y Clotting of blood in circuit
y Air embolism
y Leakage
y ARDS
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Profile of Medtronic heart
Valves
y Transforms open heart surgical aortic valve replacement into
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a beating heart procedure.
Delivery profile: 18 Fr(1Fr=0.333mm) delivery profile
Unique coverage sheath protects valve during delivery to the
point of deployment.
Valve able to be repositioned proximally at any point prior
to full deployment.
No rapid pacing required through deployment.
Diksha Wadhwa, Final Year
Gillian Lieberman, MD
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
PIVOTAL MEDTRONIC COREVALVE RANDOMISED TRIAL IN
THE US
y The US CoreValve Pivotal Trial is an ongoing clinical study
designed to assess the safety and efficacy of the 18Fr
CoreValve percutaneous aortic valve in patients at « HighRisk » or « Extreme-Risk » for surgical aortic valve
replacement (sAVR)
y A total of 487 patients treated by the iliofemoral approach
will be included in this Registry. An additional 100 patients
non ilio-femoral access (subclavian or direct aortic) will also
be enrolled and analyzed separately from the primary cohort.
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
Concerns associated with medtronic heart
valves
y Risk of stroke
y Risk of peripheral vascular disease
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
References
y PACS
y www.heartvalvesurgery.com
y www.massgeneral.org
y www.columbiasurgery.com
y www.medicore.com
y www.medscape.com
y www.nejm.org
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Diksha Wadhwa, Final Year
Gillian Lieberman, MD
ACKNOWLEDGMENT
DR. GILIAN LIEBERMAN
DR. IAN BRENNAN
DR. DIANA LITMANOVICH
MS. EMILY HANSON
MS. CLAIRE ODOM
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