• Assembling the “Heart team” : Dynamics , Decision making and Collaboration During Procedures

    Alec Vahanian, FESC, FRCP Bichat Hospital, Paris Honoraria- Valtech Edwards Lifesciences Medtronic Abbott Disclosures Relationship with companies who manufacture products used in the treatment of the subjects under discussion Relationship Manufacturer(s) Speaker's Honoraria Edwards Lifesciences Consultant (Advisory Board) Medtronic, Abbott, Valtech (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29- 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4-193-199) A group of valve specialists who collaborate to- Select the most appropriate procedure Perform the procedures Evaluate the results (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29- 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4-193-199) SURGEONS CARDIOLOGISTS Imaging specialists (Echo, CT, MRI) Anesthesiologists The « Heart Team » With expertise in the treatment of valve disease EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29- 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8 Other specialists- Geriatricians …… Decision-making for intervention is multifactorial- Prognosis according to severity and consequences of valvular disease Risks and late consequences of intervention Patient life expectancy and quality of life Patient wishes after information Local resources, in particular results of surgery Risk-Benefit Assessment Good discrimination (low vs. high risk) But poor calibration (predicted vs. observed risk) (Iung Heart 2008;94-519-24) (Dewey et al. JTCS 2008;135-180-7) (Brown et al. JTCS 2008;136-566-71) PARTNER A Predicted mortality (STS ) -11.7% Observed operative mortality - 6.4% Frailty (Katz score + Ambulation Aid + Dementia) Neurological dysfunction (with functional impairment) Pulmonary disease (GOLD stage II) Peripheral vascular disease (including porcelain aorta) Renal disease (KDOQI Stage 3, GFR < 60 mL/min) Poor Metabolic state (high bilirubin, low albumin, Diabetes, hyponatraemia, PT …), BMI < 20, Liver failure (Child-Pugh)…. TAVI 354 (59%) Conventional AVR 54 (9%) Screening in Bichat among 603 High-risk Patients Referred for TAVI Medical Rx 195 (32%) « Cohort C » Who Cardiologists/ Surgeons Cardiologists/ Surgeons/ Anesthesiologists/ Geriatricians Skills Clinical/ echocardiography Clinical Decision-making for intervention is multifactorial- Prognosis according to the severity and consequences of valvular disease Risks and late consequences of intervention Patient life expectancy and quality of life Patient wishes after information Local resources, in particular results of surgery Feasibility of transcatheter intervention Measurement of aortic annulus Evaluation of calcium distribution Distance coronary – aortic valve Multi-Modality Screening before Transcatheter Aortic Valve Implantation When looking at the decision for implantation and the choice of prosthesis size based on TEE the decision would have changed in 40% of patients if MSCT was used (Messika-Zeitoun. J Am Coll Cardiol, 2010;55-186-94) LV apical thrombus Contrast echo, MSCT Dynamic subaortic obstruction Echo Severe organic MR is a contraindication but functional MR is not Conventional angio + MSCT Sagittal + transversal views Minimal diameters 18 Fr- 6mm 22 Fr- 7mm 24 Fr- 8mm Calcification (grading) Tortuosity Choice of the approach Judgement based on the combination of - Who Cardiologists/ Surgeons Cadiologists/ Surgeons/ Geriatricians Cardiologists/ Radiologists/Surgeons Skills Clinical/ echocardiography Clinical Echocardiography / CT/ MRI A group of valve specialists who collaborate to- Select the most appropriate procedure Perform the procedures Evaluate the results (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29- 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4-193-199) In cardiology and cardiac surgery centers Procedural characteristics 9.9% 15.3% 74.7% (84%) (12%) (21%) (67%) Echocardiography is Helpful in Monitoring the Procedure Echocardiography is Key for Evaluating the results New Systems for Navigation and Positioning during TAVI Percutaneous access + surgical closure Surgical access and closure Percutaneous access and closure (closure device) Transapical (Edwards Sapien) Subclavian (Medtronic CoreValve) Transaortic (Both) Coronary sinus/LVOT suitable Severe symptomatic AS Agreed high surgical risk 18-20 mm 20-25 mm 25-27 mm Re-evaluate surgical options Proximal ascending aorta =40 mm (20-23 mm annuli) = 43 mm (23-27 mm annuli) Femoral sizing angio/CT/both Fem = 6 mm CoreValve Transaxillary Axillary = 6 mm Direct Aortic Access CoreValve Transfemoral Edwards Transfemoral Edwards Transapical Femoral sizing angio/CT/both Femoral>6mm yes yes yes yes no no no no no (Jilaihawi. JACC- Cardiovasc Int 2010;3-859-66.) or « Complementary Techniques » angio Dissection Stenting Final Result Traumatic Iliac Dissection « Be prepared » Who Cardiologists/surgeons Cardiologists/surgeons/ Geriatricians Cardiologists/surgeons/ radiologists Interventionists/ echocardiographists/ anesthesiologists/ surgeons/paramedical staff of cath lab Skills Clinical /echocardiography Clinical Echocardiography/CT Working in a sterile environment/valvular catheterization/balloon valvuloplasty/vascular access/peripheral intervention /valve surgery/cardiac assistance Who Interventionists/ anesthesiologists/ surgeons/ paramedical staff of cath lab and/or Cardiologists/surgeons/ anesthesists/intensive care/EP specialists Skills Working in a sterile environment/Valvular catheterization/balloon valvuloplasty/vascular access/peripheral intervention/monitoring/valve surgery/Cardiac assistance Post operative care Current pathway Cross training Bench training and Simulators Animal lab PCR / TCT / CRT /JIM / ICI ........... Industry sponsored postgraduate courses Scientific Societies sponsored postgraduate courses Accredited postgraduate residency or fellowship training program Select most appropriate procedure Perform it Evaluate the results The “Heart Team” As well as enrolment in randomized clinical trials, data should be accumulated in registries with F.U. In centres performing TAVI, multidisciplinary meetings should be held to discuss indications, procedural techniques, and case outcomes. Hospitals should keep proof of close medico-surgical collaboration and maintain a log of all patients referred to TAVI for continuous evaluation of the programme (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29- 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4-193-199) Team members must learn to collaborate, select the best candidates, perform the procedure and evaluate the results Institutional and individual training is necessary The appropriate environment must be available in terms of sterility, imaging, access to surgery and cardiac support “We may have all come in different ships, but we’re in the same boat now” Martin Luther King, Jr. Strokes 2-7% Vascular complications 2-16% Aortic regurgitation 5-10% (mod./severe) Pace maker 4-6 % ES

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