What's New in Cardiac, NCANA 3 & 4 Meeting

1. What’s new inWhat’s new 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. disclaimersdisclaimers
• NONENONE

3. WatchmanWatchman boston Scientificboston Scientific
• 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

5. Major culpritMajor culprit

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
strokes from 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 strokesPrevention of 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 strokesPrevention of 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 strokesPrevention of 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 strokesPrevention of strokes
• LAA closureLAA closure
• SurgicalSurgical
• Atriclip deviceAtriclip device
• CPBCPB
• Flaccid heartFlaccid heart

12. WatchmanWatchman
DeviceDevice
FDA approved in 2015FDA approved in 2015
For non-valvular AFibFor non-valvular AFib

13. WatchmanWatchman
• Patient considerationsPatient considerations
• 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. WATCHMAN:WATCHMAN:
• Healing:Healing:

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 jude medicalSt jude medical
• AmplatzerAmplatzer

20. Amplatzer,Amplatzer, St jude medicalSt 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 Valve ReplacementTranscatheter 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. corevalvecorevalve
• MedtronicMedtronic
• Self-expandingSelf-expanding

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
Valve Sheath 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:
femoral approachfemoral 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:
femoral approachfemoral approach

34. ApproachesApproaches

35. ApproachesApproaches
• TransaxillaryTransaxillary

36. Hybrid orHybrid or

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 vs MAC*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
• Requires GARequires 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 staffOR staff
• Cath lab staffCath lab staff
• CPB machineCPB machine
• FluoroFluoro
• PerfusionPerfusion
• 3 big dogs3 big dogs

47. PARTNER IIA TRIALPARTNER IIA 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 ACADEMIC RESEARCH 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. MitraClipMitraClip™™ abbott Vascularabbott Vascular

51. MitralMitral
regurgitationregurgitation
Most common insufficient valve disease

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 leafletAnterior 2 leaflet
A2A2
Posterior leafletPosterior leaflet
P2P2
Figure 8Figure 8

55. Mitraclip,Mitraclip, Abbott vascularAbbott vascular

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 MIRecent MI
• 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. procedureprocedure

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 mitral leaflet(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
• 2 large 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/ hybrid ORCath lab/ hybrid ORArrangementsin the ca

65. FutureFuture
• EVEREST II TrialEVEREST 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