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Karl Eugen Hauptmann , MD Trier - Germany

March 9 – 14 ,2014. Karl Eugen Hauptmann , MD Trier - Germany. Nothing to disclose. Krankenhaus der Barmherzigen Brüder Trier. „Heart navigator “ and alternative access improves Patient selection and outcome of TAVI. Karl Eugen Hauptmann. Isolated aortic valve replacement

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Karl Eugen Hauptmann , MD Trier - Germany

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  1. March 9 – 14 ,2014 Karl Eugen Hauptmann , MD Trier - Germany Nothingtodisclose

  2. Krankenhaus der Barmherzigen Brüder Trier „Heart navigator“ and alternative accessimproves Patient selectionandoutcomeof TAVI. Karl Eugen Hauptmann

  3. Isolatedaorticvalvereplacement Germany 2000 - 2012

  4. GARY ( German AorticValve Registry )07.2010 – 07.2012 26 000 PatientResultofthefirst 13 860 AVR TAVI Age m.: fem.: 81,0 ap. : 80,3 Mort. i. h. : fem.: 5,1 % ap. : 7,7% • Age mean: 68,3 • Mortality in hospital 2,1 % , + By. 4,5% Itis not bad But not optimal

  5. Early TAVI Devices for Severe Aortic StenosisSignificant benefit for inoperable/high-risk patients, but… • Paravalvular regurgitation • Associated with increased mortality* • Valve malpositioning • Valve migration, embolization, ectopic deployment, TAV-in-TAV • Stroke Current devices have limitations 2nd generation devices should • Reduce aortic regurgitation • Have simple, precise & atraumatic aortic/ventricular repositioning • Allow full atraumatic retrieval Weare not sureiftheoutcomeofthe 2nd generationisbetter. *Kodali, NEJM 2012;366:1685; Tamburino, Circ 2011;123:299; Abdel-Wahab, Heart 2011;97:899

  6. Heart Team: ? Howtoimprovetheoutcomeofourveryoldpatients ? Wecheckedthe last 200 patients, anddiscussedthepatientswhichdiedwithin 30 days. Wediscussedthefollowing:-Patient selection -Access -Way of Implantation -Amountofradiopaque -Lost of Blood Wehave not allwaysdone a perfectjob

  7. Perfect Setting: -Hybrid OP -During all proceduresoneheartsurgeonassists

  8. Werecognizedimportantparameters • Selection • Access • Procedure

  9. Foreverycandidatewe do thecommondiagnosis: TTE TEE Cardiaccatheter CT oftheheart Calcium detection Navigator

  10. Heart teamPatient selectionandtherapie • Weanalyse all theresults in theheartteam. • Bedside check thepatientstogether. • Do selection TAVI vs. Valvereplacement. • Discuss alternative accessandvalves.

  11. Alternative access

  12. Directaorticaccess Ministernotomie Minithorakotomie After somepatientswestopthiskindoftechnique. Aggresivtechnique , not minimal invasive !!!!

  13. This is not a goodcandidateforTF or TA access ! This patientis not a problemforsubclavianaccess !

  14. Subclavianaccessleftorright Positiv Negativ Take care of LIMA Pacemaker Angulation at theostium • Vesselwithlesscalcium • Rare stenosis • Lessangulation Subvlavia : Less stress forthe Aorticarche. TF

  15. A. Subclavia (Axillaris)

  16. After preperationthevesselwe fix a shortprotesis at the A. axillaris. We do thepuncturethroughtheprothesistoavoid a dissectionThanweinsert a shortsheat.

  17. A. Subclaviaaccessexperiencefrom Trier • 62 Patientssince 03.2012 • 1 dissection ( Stent implantation ) • Less lost ofblood • Lesspain • Lessdays in thehospital

  18. Alternative accessaccessselection • Directaorticaccess: wedon´tusethisaccess. • Subclavianaccess ( A. axillaris ):Ifthevesselistoosmallorthe grade ofcalcificationistoo high. …Obesity 15% We will double thenumber. • Trans apikal access: porcelainaorta, heavy calcificationofthe a. fem.. 15% • Trans femoralaccess: Most ofthepatient. Calcium at theplannedpuncturesitewe do surgicalcut. All theotherpatientweusetheaccessbydirectpuncture. Weimplant a shortcoveredstentifthevesselis not closedcompletly after usingtheclosingdevice. 70%

  19. SoftwareHeart Navigator The secondimportandchangetoimprovetheoutcomeofour TAVI patients was touse a newsoftwarewhileimplantingthevalve.

  20. HeartNavigator • Step 1: The „HeartNavigator“-software automaticallydoesthesegmentationoftheheart,based on thepre-operative CT ( LV.,theaorticvalveandtheaortaincludingthecoronaryostia ). After thatwe do additional measurements.( Annulus – LCA or RCA ) • Step 2: The HeartNavigatorautomaticallycalculatesviews in linewiththevalve. Westoretheseviewstouseitduringtheprocedure.( virtualdeviceimplantation ) Measurement of the distance between valve plane and coronary ostia Segmentation View calculation

  21. Segmentation

  22. Measurements:

  23. HeartNavigator • Step 3 : Registration :We must register 2D imagesfromthe x-raysytemwiththe CT model.Thetworegistrationrunsshouldbeacquiredwith a difference in rotation angle of at least 60 degrees. • Step 4 : Live Guidance: NowtheHeartNavigatorprovide an overlayimageshowingthefluoroscopy in relationtotheoutlineoftheaorticrootderivedfromthe CTA.

  24. Lessradiation , lesscontrastmedium Overlay – Projection = >

  25. TAVIOptimizeoutcome The combinationofteamworkand optimal techniqueoptimizetheoutcomeofourpatients. Itisveryimportanttousealwaysthebestaccessforthepatient. Weshould not hesitatetousenewtechnicalhelptoimplant TAVI

  26. Westartedtochangetheproceedings 01.07.2013 01.07.2013 – 28.02.2014 = 110 TAVI TA = 17 Subcl. = 23 TF = 70 ( surgicalaccess 50% ) Same Euroscore II and STS Score We lost 2 patientsduringthefirst 30 days. 1 Pat. at day 23 with AV-Block III, chrondialysispatient 1 PAT: day 10 , Pat. embolism a. mesentericaday 5. Weusedsignificantlessradiopaque material anddidneedsignificantlessunitsofstoredblood.

  27. Thankyou! It´sdone !

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