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What's New in Cardiac
The document discusses the Watchman device, which is used to close off the left atrial appendage (LAA) as an alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. It describes the procedure and risks of implanting the Watchman device, as well as alternatives like the Amplatzer cardiac plug. The document also discusses transcatheter aortic valve replacement (TAVR) procedures using the Edwards Sapien valve or Medtronic CoreValve to treat severe aortic stenosis as an alternative to open heart surgery for high-risk patients. Risks of TAVR like vascular injury, stroke, and paravalvular regurgitation are outlined.
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What's New in Cardiac
- 1. What’s new inWhat’snew in Cardiac?Cardiac? WatchmanWatchman Chris Saraceno, DNAP, CRNAChris Saraceno, DNAP, CRNA NCANA District 3 & 4 MeetingNCANA District 3 & 4 Meeting February 4February 4thth , 2017, 2017
- 2.
- 3. WatchmanWatchman boston ScientificbostonScientific • Atrial fibrillationAtrial fibrillation • Most common cardiac arrythmiaMost common cardiac arrythmia • Morbidity & mortality of AFibMorbidity & mortality of AFib • StrokesStrokes • 15-20% of CVAs from Afib15-20% of CVAs from Afib • ~30% CVAs in persons > 80 y.o.~30% CVAs in persons > 80 y.o. • Particularly devastatingParticularly devastating • Large emboliLarge emboli
- 4. Major culpritMajor culprit •Purpose of the LAAPurpose of the LAA • Contribute to atrial kickContribute to atrial kick • Loss of this function in AfibLoss of this function in Afib • Atrial natriuretic peptide (ANP)Atrial natriuretic peptide (ANP) • Reason for clot formation in the LAAReason for clot formation in the LAA • Shape of LAAShape of LAA
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- 6. LAA MorphologyLAA Morphology •A. Chicken wingA. Chicken wing • B. WindsockB. Windsock • Most suitable forMost suitable for WatchmanWatchman • C. Broccoli/cauliflowerC. Broccoli/cauliflower • D. CactusD. Cactus
- 7. Prevention ofPrevention of strokesfrom AFibstrokes from AFib • Stop the arrythmia:Stop the arrythmia: • Medical regimenMedical regimen • antiarrythmicsantiarrythmics • Radiofrequency Ablation (RFA)Radiofrequency Ablation (RFA) • Problem:Problem: • Typically, Afib is not eradicated with either treatmentTypically, Afib is not eradicated with either treatment • ACC Guidelines do not recommend d/c of oralACC Guidelines do not recommend d/c of oral anticoagulants (OAC)anticoagulants (OAC) ** decreased risk of CVA in patients with RFA than without** decreased risk of CVA in patients with RFA than without
- 8. Prevention of strokesPreventionof strokes from AFibfrom AFib • AnticoagulantsAnticoagulants • Warfarin-standard of careWarfarin-standard of care • Drug interactionsDrug interactions • Risk of bleedingRisk of bleeding • Narrow therapeutic rangeNarrow therapeutic range • Frequent blood testingFrequent blood testing • Poor compliancePoor compliance • Diet restrictions due to food interactionsDiet restrictions due to food interactions • Pradaxa®, Xarelto®, Eliquis®Pradaxa®, Xarelto®, Eliquis® • Risk of bleedingRisk of bleeding • No antidoteNo antidote
- 9. Prevention of strokesPreventionof strokes from AFibfrom AFib Stroke RiskStroke Risk • CHACHA22DSDS22-VASc-VASc • CHF hxCHF hx • HTN hxHTN hx • AgeAge • 65-7465-74 • >> 7575 22 • DMDM22 • Stroke/TIA/TE hxStroke/TIA/TE hx22 • Vascular diseaseVascular disease BleedingBleeding RiskRisk • HAS-BLEDHAS-BLED • HTNHTN • AbnAbn • Renal fxnRenal fxn • Liver fxnLiver fxn • StrokeStroke • BleedingBleeding • Labile INRsLabile INRs • Elderly: Age>65Elderly: Age>65 • DrugsDrugs • AlcoholAlcohol **Prevention needs to weigh risk vs benefit
- 10. Prevention of strokesPreventionof strokes from AFibfrom AFib Stroke RiskStroke Risk • CHACHA22DSDS22-VASc-VASc Bleeding RiskBleeding Risk • HAS-BLEDHAS-BLED Score Risk of bleeding 0-1 Low risk (1.1%) 2 Intermediate risk (1.9%) >3 High risk (4.9%) Score Risk of Stroke 0 Low risk (0%) 1 Intermediate risk (0.6%) >1 High risk (3%)
- 11. Prevention of strokesPreventionof strokes • LAA closureLAA closure • SurgicalSurgical • Atriclip deviceAtriclip device • CPBCPB • Flaccid heartFlaccid heart
- 12. WatchmanWatchman DeviceDevice FDA approved in2015FDA approved in 2015 For non-valvular AFibFor non-valvular AFib
- 13. WatchmanWatchman • Patient considerationsPatientconsiderations • Non-valvular AfibNon-valvular Afib • High stroke risk score*High stroke risk score* • CHACHA22DSDS22-VASc-VASc • High bleeding risk score*High bleeding risk score* • HAS-BLEDHAS-BLED *high stroke AND bleeding risk score = most suitable*high stroke AND bleeding risk score = most suitable
- 14. WatchmanWatchman preprocedurepreprocedure • CTCT •AngiographyAngiography • ShapeShape • Orifice sizeOrifice size • DepthDepth • WidthWidth
- 15. Watchman:Watchman: procedureprocedure • AccessAccess •Femoral veinFemoral vein • TranseptalTranseptal • GA/MACGA/MAC • TEETEE • FluoroscopicFluoroscopic
- 16.
- 17. Watchman:Watchman: Anesthetic considerationsAnesthetic considerations •Cath labCath lab • EPs or interventional cardiologistsEPs or interventional cardiologists • TranseptalTranseptal • AnticoagulantsAnticoagulants • ComplicationsComplications • Procedural strokeProcedural stroke • Pericardial effusionPericardial effusion • Air embolismAir embolism • Cardiac perforationCardiac perforation • Device embolizationDevice embolization • VascularVascular • Bleeding, hematoma, pseudoaneurysmBleeding, hematoma, pseudoaneurysm
- 19. Amplatzer,Amplatzer, St judemedicalSt jude medical • AmplatzerAmplatzer
- 20. Amplatzer,Amplatzer, St judemedicalSt jude medical • Amplatzer Cardiac PlugAmplatzer Cardiac Plug • Amplatzer AmuletAmplatzer Amulet
- 21. Other devicesOther devices •Coherex Wavecrest LAA occluderCoherex Wavecrest LAA occluder • Still others:Still others: • OCCLUTECH LAA OCCLUDEROCCLUTECH LAA OCCLUDER • LIFETECH LAA OCCLUDER: LambreLIFETECH LAA OCCLUDER: Lambre • Cardia ultrasept LAA OCCLUDERCardia ultrasept LAA OCCLUDER • AEGIS-ECG guided LAA capture andAEGIS-ECG guided LAA capture and ligation systemligation system • EPITEK- fiberoptic endoscope mediatedEPITEK- fiberoptic endoscope mediated
- 22. LARIAT™LARIAT™ • LARIAT™ DeviceLARIAT™Device • SentreheartSentreheart • Redwood City, CARedwood City, CA
- 23. Post watchmanPost watchman •Oral anticoagulants**Oral anticoagulants** • Dual antiplatelet therapyDual antiplatelet therapy
- 24. TAVRTAVR Transcatheter Aortic ValveReplacementTranscatheter Aortic Valve Replacement
- 25. AORTIC valveAORTIC valve •Valve areaValve area • Normal: 2.6-3.5 cmNormal: 2.6-3.5 cm22 • Moderate: 1-1.5 cmModerate: 1-1.5 cm22 • Severe: <1.0 cmSevere: <1.0 cm22 • Pressure gradientPressure gradient • Normal: < 10 mmHgNormal: < 10 mmHg • Moderate: 0.6-0.85 mmHgModerate: 0.6-0.85 mmHg • Severe: < 0.6 mmHgSevere: < 0.6 mmHg
- 26. Aortic stenosisAortic stenosis •Mortality with onsetMortality with onset of symptoms:of symptoms: • Angina: first symptom inAngina: first symptom in 2/3 pts2/3 pts • < 5 yrs< 5 yrs • Syncope: first symptomSyncope: first symptom in 15-30% of ptsin 15-30% of pts • 3-4 yr life expenctancy3-4 yr life expenctancy • CHFCHF • 1-2 yr life expenctancy1-2 yr life expenctancy • Risk of sudden cardiacRisk of sudden cardiac deathdeath
- 27. Aortic valveAortic valve Repair/replacementRepair/replacement •Current treatmentCurrent treatment • Gold standard: AVRGold standard: AVR • Morbidity and mortalityMorbidity and mortality • Non-surgical candidates?Non-surgical candidates? • PARTNER TRIALPARTNER TRIAL • Placement of Aortic Transcatheter ValvesPlacement of Aortic Transcatheter Valves • Superior to standard therapySuperior to standard therapy • Equivalent to surgery in high-risk patientsEquivalent to surgery in high-risk patients
- 28. Sapien/sapien xtSapien/sapien xt •Edwards LifesciencesEdwards Lifesciences • First human implant 2002First human implant 2002 • FDA approved 2011FDA approved 2011
- 29.
- 30. Pre-procedure evalPre-procedure eval •EchoEcho • ANNULUS SIZEANNULUS SIZE • CalcificationCalcification • Severity of ASSeverity of AS • Other valve diseaseOther valve disease • AngiographyAngiography • Vascular surrounding aortic valve **aortaVascular surrounding aortic valve **aorta • Heart cathHeart cath • Pulmonary HTN?Pulmonary HTN? • CAD?CAD? • CTCT • IliacsIliacs • FemoralsFemorals
- 31. Sapien/sapien xtSapien/sapien xt ValveSheath Minimal arteral diameter Sapien 23 mm 22 F 7 mm 26 mm 24 F 8 mm Sapien XT 23 mm 18 F 6 mm 26 mm 19 F 6.5 mm Edwards Lifesciences
- 32. Tavr procedure:Tavr procedure: femoralapproachfemoral approach • PrepPrep • TimeoutTimeout • EquipmentEquipment • AntibioticAntibiotic • AccessAccess • Femoral arterial accessFemoral arterial access • Aortic angiographyAortic angiography • Femoral venous accessFemoral venous access • Pacer wire in right ventriclePacer wire in right ventricle • Rapid ventricular pace @ 180-Rapid ventricular pace @ 180- 200 bpm200 bpm • Heparinize prior to traversingHeparinize prior to traversing aortic valveaortic valve • Valvuloplasty with rapid pacingValvuloplasty with rapid pacing • DeliveryDelivery • Balloon deflated & withdrawnBalloon deflated & withdrawn
- 33. Tavr procedure:Tavr procedure: femoralapproachfemoral approach
- 34.
- 35.
- 36.
- 37. Tavr complicationsTavr complications •Structural failure-rareStructural failure-rare • Vascular injury/ perforationVascular injury/ perforation • Iliacs, femorals, aortaIliacs, femorals, aorta • RETROPERITONEAL BLEEDRETROPERITONEAL BLEED • IVUSIVUS • ThrombusThrombus • Heparinize, ACT 250-300 seconds, check q 30 minutesHeparinize, ACT 250-300 seconds, check q 30 minutes • Cerebral embolizationCerebral embolization
- 38. Tavr complicationsTavr complications •Acute coronary obstructionAcute coronary obstruction • Displaced native valveDisplaced native valve • DeviceDevice • Coronary ostia not far from aortic valveCoronary ostia not far from aortic valve • even smaller in AS ptseven smaller in AS pts ** Left main: CPB, device explantation, AVR** Left main: CPB, device explantation, AVR
- 39. Tavr complicationsTavr complications •Mitral valve injuryMitral valve injury • Impede anterior leaflet ofImpede anterior leaflet of mitral valvemitral valve
- 40. Tavr complicationsTavr complications •Annular and aortic root rupture/dissectionAnnular and aortic root rupture/dissection • Device too largeDevice too large • Risk increases with manipulation of deviceRisk increases with manipulation of device • Perivalvular regurgitationPerivalvular regurgitation • Inappropriate sizing- too smallInappropriate sizing- too small • * embolize device* embolize device • Malposition (valve in valve)Malposition (valve in valve) • Under expansion of deviceUnder expansion of device
- 41. Tavr complicationsTavr complications •AV blockAV block • 1.8-8.5%1.8-8.5% • AnnuloplastyAnnuloplasty • RBBB- increases riskRBBB- increases risk of AV blockof AV block • PacemakerPacemaker
- 42. Tavr complicationsTavr complications •Cardiac perforation & tamponadeCardiac perforation & tamponade • Echo-pericardiocentesisEcho-pericardiocentesis • Emolization of deviceEmolization of device • Into LV- fatalInto LV- fatal • Inverted valve - fatalInverted valve - fatal
- 43. Tavr complicationsTavr complications •Cardiogenic shockCardiogenic shock • Patients with severe LVPatients with severe LV dysfxn + rapid pacingdysfxn + rapid pacing • Muscle collapsesMuscle collapses • ? fluid? fluid
- 44. AnestheticAnesthetic considerationsconsiderations • GA vsMAC*GA vs MAC* • TEETEE • APPROACHAPPROACH • 2 lg bore IVs2 lg bore IVs • Arterial lineArterial line • 2 pacers2 pacers • VasopressorsVasopressors • Cardiac CRNACardiac CRNA • Cardiac anesthesiologistCardiac anesthesiologist
- 45. AnestheticAnesthetic considerationsconsiderations • TransapicalTransapical • RequiresGARequires GA • Left thoracotomyLeft thoracotomy • Double lumen tubeDouble lumen tube • Transaortic/ transaxillaryTransaortic/ transaxillary • Requires GARequires GA • Double lumen tube/BBDouble lumen tube/BB
- 46. AnestheticAnesthetic considerationsconsiderations • OR staffORstaff • Cath lab staffCath lab staff • CPB machineCPB machine • FluoroFluoro • PerfusionPerfusion • 3 big dogs3 big dogs
- 47. PARTNER IIA TRIALPARTNERIIA TRIAL • December 2011-NovemberDecember 2011-November 20132013 • Severe ASSevere AS • Intermediate riskIntermediate risk • 1011 patients1011 patients • RandomizedRandomized • 57 centers in U.S. and57 centers in U.S. and CanadaCanada • Results:Results: • Pacemaker requirementsPacemaker requirements • No change fromNo change from PARTNER TrialPARTNER Trial • Aortic regurgitationAortic regurgitation • 3.7%3.7% • Not related to adverseNot related to adverse outcomesoutcomes 2016 FDA approves Sapien XT & Sapien 3 for intermediate risk
- 48. Sapien 3Sapien 3 •Base on data fromBase on data from PARTNER II TrialPARTNER II Trial • Paravalvular leakParavalvular leak • Skirt of fabric at base ofSkirt of fabric at base of devicedevice
- 49. VARCVARC • VALVE ACADEMICRESEARCH CONSORTIUMVALVE ACADEMIC RESEARCH CONSORTIUM • ComplicationsComplications • Stroke & TIAsStroke & TIAs • ARAR • Vascular access complicationsVascular access complications • Conduction system disturbancesConduction system disturbances • Coronary artery occlusionCoronary artery occlusion • ARFARF
- 50.
- 51.
- 52. Current therapyCurrent therapy •Mitral repairMitral repair • Low risk mortality: 1.4%Low risk mortality: 1.4% • Hight risk mortality/ age > 80: 11%Hight risk mortality/ age > 80: 11% • Mitral replacementMitral replacement • Low risk mortality: 1.6%Low risk mortality: 1.6% • Hight risk mortality/ age > 80: 18.9%Hight risk mortality/ age > 80: 18.9% • EVEREST TRIALEVEREST TRIAL • EndoVascular Edge- to-Edge REpair StudyEndoVascular Edge- to-Edge REpair Study
- 53. Alfieri procedureAlfieri procedure •SurgicalSurgical • Alfieri suture MV repair techniqueAlfieri suture MV repair technique • AnnuloplastyAnnuloplasty • Anterior and posterior leafletsAnterior and posterior leaflets • SternotomySternotomy • CPBCPB
- 54. AlfieriAlfieri procedureprocedure Anterior 2 leafletAnterior2 leaflet A2A2 Posterior leafletPosterior leaflet P2P2 Figure 8Figure 8
- 55.
- 56. Patient selectionPatient selection •Moderate to severe MRModerate to severe MR • Non-surgical candidatesNon-surgical candidates • Excessive co-morbiditiesExcessive co-morbidities • Valve:Valve: • Mitral valve orifice area < 4 cmMitral valve orifice area < 4 cm22 • Degenerative MR: flail height/Degenerative MR: flail height/ widthwidth • Functional MR: grasping areaFunctional MR: grasping area
- 57. exclusionexclusion • Recent MIRecentMI • MR with rheumatic heart diseaseMR with rheumatic heart disease • EndocarditisEndocarditis • Abnormal leafletAbnormal leaflet
- 58. procedureprocedure • Prep, time-outPrep,time-out • Access femoral veinAccess femoral vein • Transeptal punctureTranseptal puncture • Heparin, ACT >250, check q 30 minHeparin, ACT >250, check q 30 min • Steerable Guide catheter (SGC)Steerable Guide catheter (SGC) • Clip Delivery SystemClip Delivery System • Mitraclip above mitral valveMitraclip above mitral valve • Mitral clip into LVMitral clip into LV • Grasp leafletsGrasp leaflets
- 60.
- 61. procedureprocedure • AssessAssess • Echo& fluoroEcho & fluoro • MR < 2+MR < 2+ • Improved COImproved CO • Decreased wedgeDecreased wedge • Decreased LVEDV pressureDecreased LVEDV pressure • Mitraclip releaseMitraclip release • Position and reduction inPosition and reduction in MR satisfactoryMR satisfactory • RepositionReposition • Second clipSecond clip
- 62. complicationscomplications • Tear mitralleaflet(s)Tear mitral leaflet(s) • Worsen MRWorsen MR • Mitral stenosisMitral stenosis • Acute or chronicAcute or chronic • Clip surfaces endothelializeClip surfaces endothelialize • Create an atrial-septal defectCreate an atrial-septal defect • Rupture of atrial wallsRupture of atrial walls • Cardiac tamponadeCardiac tamponade • Echo-guided pericardiocentesisEcho-guided pericardiocentesis
- 63. AnestheticAnesthetic considerationsconsiderations • GAGA • 2large bore IVs2 large bore IVs • Arterial lineArterial line • VasopressorsVasopressors • Phenylephrine vs ephedrinePhenylephrine vs ephedrine • ? fluids? fluids • PatientPatient • LV dysfxnLV dysfxn • Pulmonary HTNPulmonary HTN • ? Afib? Afib
- 64. Cath lab/ hybridORCath lab/ hybrid ORArrangementsin the ca
- 65. FutureFuture • EVEREST IITrialEVEREST II Trial • 20152015 • 5 year follow up:5 year follow up: • If intervention required (surgery): first 6 monthsIf intervention required (surgery): first 6 months • After 1 year- cardiac remodelingAfter 1 year- cardiac remodeling • Clinical outcomes similar to surgical approachClinical outcomes similar to surgical approach • ** greater level of safety** greater level of safety
Editor's Notes
- #4 De Backer O, Arnous S, Ihlemann N, et al Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update Open Heart 2014;1:e000020. doi: 10.1136/openhrt-2013-000020
- #7 De Backer O, Arnous S, Ihlemann N, et al Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update Open Heart 2014;1:e000020. doi: 10.1136/openhrt-2013-000020
- #8 De Backer O, Arnous S, Ihlemann N, et al Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update Open Heart 2014;1:e000020. doi: 10.1136/openhrt-2013-000020 ACC
- #11 Birmingham 2009
- #17 www.Theafibclinic.com
- #18 Iskandar, et al 2016
- #24 ** studies showing may not need OACs
- #27 Hensley 5th Ed. P. 323-325
- #29 Sapien: trileaflet, bovine, stainless steal, durability &gt; 10 yrs Sapien XT: cobalt chromium alloy
- #53 Deuschl, et al 2016
- #63 Abbott Vascular, Abbott Park, Illionois